NCLEX-RN
Med Surg RN NCLEX Questions Questions
Extract:
Question 1 of 5
A health care provider has just inserted nasal packing for a client with epistaxis. The client is taking ramipril (Altace) for hypertension. What should the nurse instruct the client to do?
Correct Answer: D
Rationale: Avoiding rigorous aerobic exercise prevents increased blood pressure, which could worsen epistaxis. Aspirin increases bleeding risk. Omitting ramipril is not indicated without physician guidance. Removing packing is unsafe and should be done by a healthcare provider.
Question 2 of 5
In the oliguric phase of acute renal failure, the nurse should assess the client for:
Correct Answer: A
Rationale: Pulmonary edema is a risk in the oliguric phase due to fluid overload from reduced urine output.
Question 3 of 5
A client with iron deficiency anemia is refusing to take the prescribed oral iron medication because the medication is causing nausea. The nurse should do which of the following? Select all that apply.
Correct Answer: A,B,E
Rationale: Nausea and vomiting are common adverse effects of oral iron preparations. The nurse should first ask the client why she does not want to take the oral medication, and then suggest ways to decrease the nausea and vomiting. Ginger may help minimize the nausea and the client can try this remedy and evaluate its effectiveness. Iron should be taken on an empty stomach but can be taken with orange juice to enhance absorption and potentially reduce nausea. The client can evaluate if this helps the nausea. Stool softeners are not typically recommended for iron deficiency anemia, as constipation is better managed with a high-fiber diet. Intramuscular iron is a last resort and not appropriate unless oral administration is ineffective.
Question 4 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 5 of 5
A client with a hemorrhagic stroke is slightly agitated, heart rate is 118, respirations are 22, bilateral rhonchi are auscultated, SpO2 is 94%, blood pressure is 144/88, and oral secretions are noted. What order of interventions should the nurse follow when suctioning the client to prevent increased intracranial pressure (ICP) and maintain adequate cerebral perfusion?
Order the Items
Source Container
Correct Answer: B,D,A,C
Rationale: The correct order is: 1) Hyperoxygenate to prevent hypoxia (
B); 2) Provide sedation to reduce agitation and ICP spikes (
D); 3) Suction the airway to clear secretions (
A); 4) Suction the mouth to remove residual secretions (
C). This sequence minimizes ICP increases and ensures oxygenation.