NCLEX-RN
NCLEX RN Medical Surgical Questions Questions
Extract:
Question 1 of 5
A client with macrocytic anemia has a burn on her foot and states that she had been watching television while lying on a heating pad. Which action should be the nurse's first response?
Correct Answer: B
Rationale: Macrocytic anemia, often due to vitamin B12 or folate deficiency, can cause peripheral neuropathy, leading to diminished sensations and increased risk of burns from prolonged heat exposure. The nurse's first action should be to check for sensory deficits to assess the underlying cause of the injury. Assessing for abuse, documenting, or dressing the wound are secondary actions.
Question 2 of 5
A client is scheduled for an elective splenectomy. Immediately before the client goes to surgery, the nurse should determine that the client has:
Correct Answer: B
Rationale: Verifying that the client has signed the consent form is the priority before surgery to ensure informed consent and legal compliance. Voiding, recording vital signs, and checking the name band are also important but secondary to consent verification.
Question 3 of 5
The nurse should teach the neutropenic client and the family to avoid which of the following?
Correct Answer: A
Rationale: Neutropenic clients should avoid suppositories or enemas, as they can cause rectal trauma and introduce infections. HEPA masks, perianal care, and oral care are recommended to reduce infection risk.
Question 4 of 5
The nurse is planning care with a client with acute leukemia who has mucositis. The nurse should advise the client that after every meal and every four hours while awake the client should use:
Correct Answer: C
Rationale: Mucositis in leukemia clients requires gentle oral care to prevent infection and promote healing. Saline or baking soda solution is soothing and non-irritating. Lemon-glycerin swabs can dry the mucosa, commercial mouthwash may irritate, and brushing may cause trauma.
Question 5 of 5
A client with advanced Hodgkin's disease is admitted to hospice because death is imminent. The goal to address for the client is:
Correct Answer: A
Rationale: In hospice care for advanced Hodgkin's disease, the primary goal is to address fear of pain, ensuring comfort as death approaches. Fear of therapy, isolation, and social inadequacy are less relevant at this stage.