NCLEX-RN
NCLEX RN Med Surg Questions Questions
Extract:
Question 1 of 5
A client with diverticulitis has developed peritonitis following diverticular rupture. The nurse should assess the client to determine which of the following? Select all that apply.
Correct Answer: B,C
Rationale: In peritonitis, the nurse should percuss the liver for lack of dullness (
B), indicating free air, and monitor vital signs for fever, tachypnea, and tachycardia (not bradycardia) (
C). Resonance and tympany, polyphagia, polydipsia, and bowel sound frequency are less specific for peritonitis. CN: Physiological adaptation; CL: Analyze
Question 2 of 5
A client is admitted to the emergency department complaining of severe abdominal pain. A radiograph reveals a large abdominal aortic aneurysm. The primary goal at this time is to:
Correct Answer: C
Rationale: A large abdominal aortic aneurysm with severe pain suggests impending rupture, requiring emergency surgery to prevent catastrophic bleeding. Preparing the client for surgery is the primary goal, as it addresses the life-threatening condition. Circulation, pain, and breathing exercises are managed perioperatively.
Question 3 of 5
A 21-year-old male client is transported by ambulance to the emergency department after a serious automobile accident. He complains of severe pain in his right chest where he struck the steering wheel. Which is the primary client goal at this time?
Correct Answer: B
Rationale: Maintaining adequate oxygenation is the primary goal in chest trauma to prevent hypoxia from pneumothorax or hemothorax. Anxiety, pain, and volume are secondary priorities.
Question 4 of 5
A client with ulcerative colitis is prescribed mesalamine (Asacol). The nurse should instruct the client to report which of the following side effects immediately?
Correct Answer: C
Rationale: Worsening diarrhea in a client with ulcerative colitis taking mesalamine may indicate a lack of therapeutic response or a serious adverse effect, requiring immediate reporting. Mild headache, slight rash, and fatigue are less urgent but should be monitored. CN: Pharmacological and parenteral therapies; CL: Synthesize
Question 5 of 5
The nurse is caring for a client who has just had an upper GI endoscopy. The client's vital signs must be taken every 30 minutes for 2 hours after the procedure. The nurse assigns an unlicensed nursing personnel (UAP) to take the vital signs. One hour later, the UAP reports the client, who was previously afebrile, has developed a temperature of 101.8°F (38.8°C). What should the nurse do in response to this reported assessment data?
Correct Answer: A
Rationale: A sudden fever after an upper GI endoscopy may indicate a serious complication, such as perforation, requiring immediate nursing assessment. The other options delay appropriate intervention or do not address the potential severity of the situation.