NCLEX-RN
NCLEX RN Med Surg Questions Questions
Extract:
Question 1 of 5
A client with an ileal conduit has a rash around the stoma. The nurse should:
Correct Answer: B
Rationale: Cleaning with soap and water removes irritants, promoting rash healing.
Question 2 of 5
What is a goal of care for a client with acute renal failure?
Correct Answer: A
Rationale: Maintaining adequate urine output indicates improving renal function.
Question 3 of 5
A client's bone marrow report reveals normal stem cells and precursors of platelets (megakaryocytes) in the presence of decreased circulating platelets. The nurse recognizes a knowledge deficit when the client makes which of the following statements?
Correct Answer: B
Rationale: Normal stem cells and megakaryocytes with decreased circulating platelets suggest a peripheral destruction issue, such as ITP, not a bone marrow production problem. The client's statement that the report is 'normal' indicates a misunderstanding, as the low platelet count is abnormal and requires management. The other statements reflect appropriate awareness of bleeding risks.
Question 4 of 5
What should the nurse include in the care plan for a client with a spinal cord injury?
Correct Answer: A
Rationale: Frequent repositioning prevents pressure ulcers in clients with spinal cord injuries.
Question 5 of 5
During an initial assessment of a client diagnosed with vasospastic disorder (Raynaud's phenomenon), the nurse notes a sudden color change to white in the fingers. The nurse should first assess:
Correct Answer: B
Rationale: A sudden color change to white in Raynaud's indicates vasospasm. Assessing the radial pulse first confirms whether blood flow is present despite the vasospasm, guiding further action. Cyanosis, SpO2, and blood pressure are secondary, as pulse assessment is more immediate and specific.