NCLEX-RN
NCLEX RN Medical Surgical Practice Questions Questions
Extract:
Question 1 of 5
A client with a total hip replacement asks about resuming sexual activity. Which response by the nurse is most appropriate?
Correct Answer: B
Rationale: Avoiding excessive hip flexion prevents dislocation during sexual activity post-hip replacement.
Question 2 of 5
The nurse is assessing a client who has a chest tube connected to a water-seal chest tube drainage system. According to the illustrationshown, which should the nurse do?
Correct Answer: D
Rationale:
To promote chest tube drainage the drainage system must be lower than the client's lungs. The amount of drainage is not abnormal; it is not necessary to notify the physician. The nurse should chart the amount and color of drainage every 4 to 8 hours.
Question 3 of 5
If a client is receiving rescue breaths and the chest wall fails to rise during cardiopulmonary resuscitation, the rescuer should first:
Correct Answer: D
Rationale: Failure of the chest to rise during rescue breaths suggests airway obstruction or improper positioning. Repositioning the airway (e.g., head-tilt-chin-lift) is the first step.
Question 4 of 5
A client has been diagnosed with vasospastic disorder (Raynaud's phenomenon) on the tip of the nose and fingertips. The physician has prescribed reserpine (Serpasil) to determine if the client will obtain relief. The client's history reveals that he lives in Vermont and works outside in the logging industry. He smokes two packs of cigarettes a day. Which of the following components are an important part of the discharge plan for this client? Select all that apply.
Correct Answer: A,B,D,E
Rationale: Rationales:
A) Stopping smoking reduces vasoconstriction triggered by nicotine, critical in Raynaud's.
B) Face covering and gloves protect against cold, a trigger for vasospasm.
D) Working in a warm environment minimizes cold exposure. E) Reserpine may cause orthostatic hypotension, requiring monitoring.
C) Cool water worsens vasospasm; warm water is recommended.
Question 5 of 5
The nurse is obtaining a blood sample for a PTT test ordered for a client who is taking heparin. It is 5 a.m. When drawing the blood, the nurse should do which of the following? Select all that apply.
Correct Answer: B,C,E
Rationale: Rationales:
B) Checking the armband ensures correct client identification, critical for safety.
C) Labeling the vial in front of the client prevents errors. E) Asking the client to state their name confirms identity.
A) Awakening the client is unnecessary if asleep, as the draw can be done gently.
D) Room number is unreliable for identification.