Questions 108

NCLEX-RN

NCLEX-RN Test Bank

Med Surg RN NCLEX Practice Questions Questions

Extract:


Question 1 of 5

A client with cirrhosis begins to develop ascites. Spironolactone (Aldactone) is prescribed to treat the ascites. The nurse should monitor the client closely for which of the following drug-related adverse effects?

Correct Answer: B

Rationale: Spironolactone, a potassium-sparing diuretic, can cause hyperkalemia (
B), a critical adverse effect. Constipation (
A), irregular pulse (
C), and dysuria (
D) are not commonly associated.

Question 2 of 5

The client is to be discharged on a low-fat, low-cholesterol, low-sodium diet. Which of the following should be the nurse's first step in planning the dietary instructions?

Correct Answer: D

Rationale: Assessing food preferences ensures the dietary plan is tailored and practical.

Question 3 of 5

A client with cancer has diarrhea and a nursing diagnosis of Impaired skin integrity related to the frequent diarrhea. Which of the following nursing interventions is appropriate for this diagnosis?

Correct Answer: D

Rationale: Cleaning with unscented soap and water, rinsing, and patting dry after each bowel movement prevents skin breakdown and maintains integrity in clients with diarrhea.

Question 4 of 5

The nurse is monitoring a client after an above-the-knee amputation and notes that blood has saturated through the client and the dressing. The nurse should immediately:

Correct Answer: C

Rationale: Blood saturating the dressing post-amputation suggests significant bleeding, a potential emergency. The nurse should immediately call the physician for evaluation and intervention. Applying a tourniquet is extreme and requires an order, assessing vital signs is secondary, and elevating with a pillow may not address the bleeding source.

Question 5 of 5

The nurse has an order to administer 2 oz of lactulose (Cephulac) to a client who has cirrhosis. How many milliliters of lactulose should the nurse administer?

Correct Answer: 60 mL

Rationale: 2 oz = 60 mL (1 oz = 30 mL). Thus, the nurse should administer 60 mL of lactulose.

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