NCLEX-RN
NCLEX RN Medical Surgical Questions Questions
Extract:
Question 1 of 5
A client with a history of renal calculi formation is being discharged after surgery to remove the calculus. What instructions should the nurse include in the client's discharge teaching plan?
Correct Answer: A,B
Rationale: High fluid intake (2-3 L) prevents stone recurrence, and straining urine monitors for stone passage. Dairy restriction or urine alkalinization depends on stone type.
Question 2 of 5
A client with macrocytic anemia has a burn on her foot and states that she had been watching television while lying on a heating pad. Which action should be the nurse's first response?
Correct Answer: B
Rationale: Macrocytic anemia, often due to vitamin B12 or folate deficiency, can cause peripheral neuropathy, leading to diminished sensations and increased risk of burns from prolonged heat exposure. The nurse's first action should be to check for sensory deficits to assess the underlying cause of the injury. Assessing for abuse, documenting, or dressing the wound are secondary actions.
Question 3 of 5
Which of the following interventions should the nurse anticipate incorporating into the client's plan of care when hepatic encephalopathy initially develops?
Correct Answer: D
Rationale: A low-protein diet (
D) reduces ammonia production in hepatic encephalopathy. NG tubes (
A), fluid restriction (
B), and albumin (
C) are not primary interventions.
Question 4 of 5
A Stage II pressure ulcer is characterized by:
Correct Answer: C
Rationale: Stage II pressure ulcers cause pain due to partial-thickness skin loss and exposed nerve endings. Redness is Stage I, and necrosis is Stage III or IV.
Question 5 of 5
When a blood transfusion is terminated following a reaction, the nurse must do which of the following? Select all that apply.
Correct Answer: A,B
Rationale: After a transfusion reaction, the nurse should send urine samples to check for hemolysis and return the remaining blood unit to the blood bank for analysis. The IV administration set is not typically returned, and while Risk Management and Infection Control may be notified, these are not immediate actions.