NCLEX-RN
NCLEX RN Medical Surgical Questions Questions
Extract:
Question 1 of 5
A client with chemotherapy-induced thrombocytopenia has a platelet count of 18,000/mm³. Which nursing intervention is most important?
Correct Answer: B
Rationale: A platelet count of 18,000/mm³ indicates severe thrombocytopenia, making monitoring for bleeding (e.g., petechiae, epistaxis) the most important intervention to prevent complications.
Question 2 of 5
The nurse teaches the client to report signs and symptoms of which potential complication after hypophysectomy?
Correct Answer: D
Rationale: Hypophysectomy can impair pituitary function, leading to hypopituitarism, with symptoms like fatigue, weakness, and hormonal deficiencies.
Question 3 of 5
Following abdominal surgery, a client refuses to deep breathe and cough every 2 hours as ordered. The nurse should do which of the following first?
Correct Answer: C
Rationale: Assessing the client's reasons for refusal identifies barriers (e.g., pain, fear), allowing tailored interventions to encourage compliance with deep-breathing exercises.
Question 4 of 5
A client refuses to remove a religious necklace before surgery despite hospital policy. The nurse's best response is:
Correct Answer: B
Rationale: Taping the necklace securely respects the client's beliefs while ensuring safety by preventing the item from interfering with the surgical field.
Question 5 of 5
A daughter is concerned that her mother is in denial when discussing her diagnosis of breast cancer because she sometimes says that breast cancer isn't that serious and changes the subject. The nurse informs the daughter that denial can be a healthy defense mechanism if it is used:
Correct Answer: D
Rationale: Denial can be healthy if it allows the client to maintain normal roles (e.g., as a mother) while gradually processing the diagnosis, as long as it doesn't interfere with treatment.