NCLEX-RN
Medical Surgical NCLEX RN Questions
Extract:
Question 1 of 5
A client with acute appendicitis develops a fever, tachycardia, and hypotension. Based on these assessment findings, the nurse should further assess the client for which of the following complications?
Correct Answer: D
Rationale: Fever, tachycardia, and hypotension in acute appendicitis suggest peritonitis, a complication from possible appendiceal rupture. Deficient fluid volume, obstruction, or ischemia are less directly indicated by these signs. CN: Physiological adaptation; CL: Analyze
Question 2 of 5
Which of the following interventions will be most effective in improving transcultural communications with the client?
Correct Answer: C
Rationale: Establishing rapport and listening to concerns fosters trust and understanding, which are essential for effective transcultural communication.
Question 3 of 5
A client has undergone a cystectomy and an ileal conduit diversion. What should the nurse incorporate into the discharge instructions? Select all that apply.
Correct Answer: A,D
Rationale: An adequate fluid intake aids in the prevention of urinary calculi and infection. Odor-producing foods should be avoided as they can affect the client's lifestyle and relationships. Minimizing activities can lead to urinary stasis, promoting infection. Alkaline urine may increase infection risk, and snug clothing is not recommended as it may irritate the stoma.
Question 4 of 5
In which of the following clients is an autotransfusion contraindicated?
Correct Answer: A,C,D
Rationale: Autotransfusion is contraindicated in cancer (risk of spreading malignant cells), contaminated wounds, or ruptured bowel (risk of infection or bacterial spread). It may be used cautiously in cardiac arrest if no other contraindications exist.
Question 5 of 5
The nurse monitors the client with pancreatitis for early signs of shock. Which of the following conditions is primarily responsible for making it difficult to manage shock in pancreatitis?
Correct Answer: B
Rationale: Fluid sequestration into the retroperitoneal space (
B) causes significant hypovolemia in pancreatitis, complicating shock management. Intestinal hemorrhage (
A), infection (
C), and cardiac output (
D) are secondary or less common contributors.