NCLEX-RN
Med Surg RN NCLEX Practice Questions Questions
Extract:
Question 1 of 5
A client with cirrhosis is receiving Lactulose (Cephulac). During the assessment the nurse notes increased confusion and asterixis. The nurse should:
Correct Answer: A
Rationale: Confusion and asterixis indicate hepatic encephalopathy, often precipitated by GI bleeding (
A), which increases ammonia levels. Holding lactulose (
B) is incorrect as it reduces ammonia. Increasing protein (
C) worsens encephalopathy. Bilirubin (
D) is unrelated to acute symptoms.
Question 2 of 5
A client in the PACU after spinal anesthesia reports a severe headache when sitting up. The nurse suspects:
Correct Answer: B
Rationale: A severe headache worsened by sitting up after spinal anesthesia is characteristic of a post-dural puncture headache due to cerebrospinal fluid leakage. This requires prompt management, such as hydration or an epidural blood patch.
Question 3 of 5
The nurse is developing the discharge teaching plan for a client after a lumbar laminectomy L4-5 who will be returning to work in 6 weeks. Which of the following actions should the nurse encourage the client to avoid?
Correct Answer: D
Rationale: Prolonged sitting can stress the surgical site and delay healing post-laminectomy.
Question 4 of 5
A 20-year-old who hit his head while playing football has a tonic-clonic seizure. Upon awakening from the seizure, the client asks the nurse, "What caused me to have a seizure? I've never had one before." Which cause should the nurse include in the response as a primary cause of tonic-clonic seizures in adults older than age 20?
Correct Answer: A
Rationale: Head trauma is a primary cause of seizures in adults over 20, especially in the context of a recent injury. Electrolyte imbalances, congenital defects, or epilepsy are less likely without additional history.
Question 5 of 5
Which intervention supports a client with expressive aphasia?
Correct Answer: C
Rationale: A communication board supports communication for clients with expressive aphasia.