NCLEX-RN
Med Surg RN NCLEX Questions Questions
Extract:
Question 1 of 5
A client with a recent total knee replacement reports swelling in the operative leg. Which nursing action is most appropriate?
Correct Answer: A
Rationale: Elevating the leg reduces swelling by promoting venous return, a standard post-surgical intervention.
Question 2 of 5
The nurse is teaching a client with a spinal fusion about body mechanics. Which client statement indicates understanding?
Correct Answer: B
Rationale: Keeping the back straight during lifting protects the surgical site and maintains spinal alignment.
Question 3 of 5
What should the nurse do first when a client with a head injury begins to have clear drainage from his nose?
Correct Answer: C
Rationale: Clear drainage from the nose after a head injury may indicate cerebrospinal fluid (CSF) leakage, a serious condition. The priority is to collect the fluid for analysis to confirm CSF and avoid infection, making providing tissues the first action. Compressing the nares or tilting the head back could increase intracranial pressure or contaminate the fluid, and an antihistamine is inappropriate without confirming the cause.
Question 4 of 5
A client receiving vent-assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. The nurse should:
Correct Answer: B
Rationale: Cluster breathing, a sign of neurological deterioration, requires immediate physician notification for evaluation and possible intervention. Adjusting ventilator settings without medical orders is inappropriate, and simply counting the rate does not address the underlying issue.
Question 5 of 5
In planning care for the client who has had a stroke, the nurse should obtain a history of the client's functional status before the stroke because?
Correct Answer: A
Rationale: A pre-stroke functional status history guides the rehabilitation plan by setting realistic goals based on prior abilities. Predicting outcomes, recognizing limitations, or expecting full recovery are secondary or unrealistic.