Questions 108

NCLEX-RN

NCLEX-RN Test Bank

Med Surg RN NCLEX Questions Questions

Extract:


Question 1 of 5

A female client who has a urinary diversion tells the nurse, 'This urinary pouch is embarrassing. Everyone will know that I'm not normal. I don't see how I can go out in public anymore.' The most appropriate nursing diagnosis for this client is:

Correct Answer: D

Rationale: The client's statement reflects distress about the urinary diversion's impact on her appearance and social life, indicating a disturbed body image.

Question 2 of 5

The client has a latex allergy. What should the nurse teach the client to do before having surgery at a free-standing surgery center? Select all that apply.

Correct Answer: A,B,C

Rationale: Treatment and diagnostic evaluation must be done in a latex-safe environment. Signs/symptoms may be mild to anaphylaxis. Clients with latex allergy are advised to notify their health care providers and to wear a medical ID; however, all metal and jewelry must be removed prior to surgery as they could conduct an electrical current.

Question 3 of 5

The nurse is reviewing the postoperative orders (see chart) just written by a physician for a client with insulin-dependent diabetes who has returned to the surgery floor from the recovery. The client has pain of 5 on a scale of 1 to 10. The hand-off report from the nurse in the recovery room indicated that the vital signs have been stable for the last 30 minutes. After obtaining the client's glucose level, the nurse should do which of the following first?

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Correct Answer: B

Rationale: The glucose level must be assessed to determine if insulin is safe to administer, as hypoglycemia could worsen with insulin. Contacting the physician ensures appropriate insulin dosing.

Question 4 of 5

The nurse is instructing the client about postsurgery activity following cataract surgery. What position should the nurse teach the client to use?

Correct Answer: A

Rationale: A semi-Fowler's position (head elevated 30-45 degrees) helps reduce intraocular pressure and swelling by promoting drainage and preventing fluid accumulation in the surgical eye.

Question 5 of 5

The nurse is administering a saturated solution of potassium iodide (SSKI). The nurse should:

Correct Answer: C

Rationale: SSKI has an unpleasant taste and can stain teeth. Diluting it with water, milk, or juice and using a straw minimizes discomfort and staining.

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