NCLEX-RN
Medical Surgical Nursing NCLEX RN Questions Questions
Extract:
Question 1 of 5
A client with diabetes mellitus comes to the clinic for a regular 3-month follow-up appointment. The nurse notes several small bandages covering cuts on the client's hands. The client says, 'I'm so clumsy. I'm always cutting my finger cooking or burning myself on the iron.' Which of the following responses by the nurse would be most appropriate?
Correct Answer: B
Rationale: Keeping cuts clean and covered prevents infection, a significant risk in diabetes due to poor wound healing.
Question 2 of 5
A client had a colectomy 8½ hours ago. She has received 1,500 mL of dextrose 5% in water with normal saline solution. The client has just used a patient-controlled analgesia pump to administer morphine for pain, has been repositioned for comfort, and has stable pulse rate, respirations, and blood pressure. What should the nurse do next?
Correct Answer: B
Rationale: Morphine can cause respiratory depression or hypotension. Assessing vital signs after PCA use ensures the client's safety and detects adverse effects promptly.
Question 3 of 5
The nurse is preparing a client for a paracentesis. The nurse should:
Correct Answer: A
Rationale: Voiding before paracentesis (
A) prevents bladder injury during the procedure. Side-lying (
B) is incorrect; upright is preferred. IV sedatives (
C) are not routine, and NPO status (
D) is unnecessary.
Question 4 of 5
What is the priority nursing action for a client with a suspected brain tumor?
Correct Answer: B
Rationale: Monitoring neurological status is the priority to detect changes associated with a brain tumor.
Question 5 of 5
At 8 a.m., the nurse reviews the amount of T-tube drainage for a client who underwent an open cholecystectomy yesterday. After reviewing the output record (see chart), the nurse should:
Correct Answer: C
Rationale: The T-tube should drain approximately 300 to 500 mL in the fi rst 24 hours and after 3 to 4 days the amount should decrease to less than 200 mL in 24 hours. With the sudden decrease in drainage at 8 a.m., the nurse should immediately assess the tube for obstruction of flow that can be caused by kinks in the tube or the client lying on the tube. Drainage color must also be assessed for signs of bleeding. The tube should not be irrigated or clamped without an order.