NCLEX-RN
NCLEX RN Med Surg Questions Questions
Extract:
Question 1 of 5
A client who was a victim of a gunshot wound was treated in the emergency department and died. What should the nurse direct the unlicensed assistive personnel (UAP) to do during postmortem care? Select all that apply.
Correct Answer: B,D
Rationale: UAP can cover the body and transport it to the morgue. Removing tubes may be restricted due to forensic needs, and notifying family or chaplain is typically a nurse's responsibility.
Question 2 of 5
Which of the following respiratory patterns indicates increasing intracranial pressure in the brain stem?
Correct Answer: A
Rationale: Slow, irregular respirations (e.g., Cheyne-Stokes or ataxic breathing) are indicative of brain stem dysfunction due to increasing intracranial pressure. Rapid, shallow respirations may indicate hypoxia, asymmetric chest excursion suggests mechanical issues, and nasal flaring is associated with respiratory distress, not specifically ICP.
Question 3 of 5
A client has a Pearson attachment on the traction setup. What is the purpose of this attachment?
Correct Answer: A
Rationale: The Pearson attachment supports the lower leg, maintaining alignment in balanced suspension traction.
Question 4 of 5
Which of the following techniques does the nurse avoid when changing a client's position in bed if the client has hemiparalysis?
Correct Answer: B
Rationale: Sliding the client can cause shear injuries to the skin, especially in hemiparalysis with reduced sensation. Rolling, lifting, or using a trapeze (if feasible) are safer techniques.
Question 5 of 5
Assessment of a client taking a nonsteroidal anti-inflammatory drug (NSAID) for pain management should include specific questions regarding which of the following systems?
Correct Answer: A
Rationale: NSAIDs commonly cause gastrointestinal side effects, such as bleeding or ulcers, so specific assessment of the GI system is critical.