NCLEX-RN
NCLEX RN Questions Medical Surgical Nursing Questions
Extract:
Question 1 of 5
A client with a diagnosis of cancer is frequently disruptive and challenges the nurse. This behavior is probably caused by:
Correct Answer: A
Rationale: Disruptive behavior in a cancer client is often driven by uncertainty and fear of recurrence, reflecting ongoing emotional distress.
Question 2 of 5
A client who was in a motor vehicle accident has a fractured mandible. Surgery has been performed to immobilize the injury by wiring the jaw. In the immediate postoperative phase, the nurse should:
Correct Answer: B
Rationale: Maintaining a patent airway is the priority in the immediate postoperative phase for a client with a wired jaw, as swelling or secretions could obstruct the airway. While the other interventions are important, airway management is the most critical.
Question 3 of 5
A client is receiving fluid replacement with Lactated Ringer's after 40% of his body was burned 10 voluto hours ago. The assessment reveals: temperature 36.2°C; heart rate 122; blood pressure 84/42; CVP 2 mm Hg; and urine output 25 mL for the last 2 hours. The I.V. rate is currently at 375 mL/hour. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse calls the healthcare provider with the recommendation for:
Correct Answer: C
Rationale: Low blood pressure, high heart rate, low CVP, and inadequate urine output indicate hypovolemia. Increasing the I.V. rate is appropriate to improve fluid resuscitation, as per burn fluid management protocols.
Question 4 of 5
Which of the following hospitalized clients is at risk to develop parotitis?
Correct Answer: C
Rationale: Dehydration and poor oral hygiene in the 80-year-old client increase the risk of parotitis due to reduced saliva production and bacterial overgrowth.
Question 5 of 5
A client was admitted to the hospital with iron deficiency anemia and blood-streaked emesis. Which question is most appropriate for the nurse to ask in determining the extent of the client's activity intolerance?
Correct Answer: A
Rationale:
To assess activity intolerance, the nurse should compare the client's current activity level with their previous capabilities. Asking about specific activities performed 6 months ago versus now provides concrete data on the extent of intolerance. The other questions are less specific and do not directly quantify changes in activity capacity.