NCLEX-RN
Medical Surgical NCLEX RN Questions
Extract:
Question 1 of 5
A client with colon cancer undergoes surgical removal of a segment of colon and creation of a sigmoid colostomy. What assessments by the nurse indicate the client is developing complications within the first 24 hours? Select all that apply.
Correct Answer: B,C,D
Rationale: A dusky stoma (
B) indicates poor blood supply, no drainage (
C) suggests obstruction or dysfunction, and fever (
D) may indicate infection, all of which are complications post-colostomy. Coarse breath sounds (
A) and decreased bowel sounds (E) are not necessarily indicative of immediate complications.
Question 2 of 5
The nurse should remind family members who are visiting a client with granulocytopenia to:
Correct Answer: B
Rationale: Hand washing is the most effective way to prevent transmission of pathogens to a granulocytopenic client, who is at high risk for infection. While avoiding colds, leaving children at home, and avoiding kissing are helpful, hand washing is the priority.
Question 3 of 5
There has been an increase in medication errors and errors in ordering laboratory studies in the emergency department. The nurse manager is conducting a staff education session on when to use "read-back" procedures. "Read-back" procedures should be performed in which of the following situations? Select all that apply.
Correct Answer: A,B,D
Rationale: Read-back procedures are required for verbal, phone, or critical result communications to ensure accuracy, especially when relayed through staff like unit secretaries.
Question 4 of 5
A client who has had a total hip replacement has a dislocated hip prosthesis. The nurse should first?
Correct Answer: D
Rationale: Notifying the surgeon is the priority, as dislocation requires urgent medical intervention.
Question 5 of 5
What is the priority intervention for a client with a suspected stroke?
Correct Answer: C
Rationale: Monitoring neurological status is the priority to detect changes and guide timely stroke intervention.