NCLEX-RN
NCLEX RN Medical Surgical Questions and Answers Questions
Extract:
Question 1 of 5
A nurse is assessing a 42-year-old client who has been receiving chemotherapy. The client has a platelet count of 22,000 cells/mm³ and has petechiae on the lower extremities. The nurse should advise the client to:
Correct Answer: D
Rationale: A platelet count of 22,000/mm³ with petechiae indicates severe thrombocytopenia, requiring urgent consultation with the oncologist for potential platelet transfusion or treatment adjustment.
Question 2 of 5
The nurse has completed an assessment on a client with a decreased cardiac output. Which findings should receive the highest priority?
Correct Answer: B
Rationale: Confusion, low urine output, and orthopnea indicate severe heart failure with potential cerebral and renal hypoperfusion, requiring immediate intervention. Other options reflect stable or less urgent findings.
Question 3 of 5
The nurse is teaching a 17-year-old client and the client's family about what to expect with high-dose chemotherapy. Which of the following side effects should be included in the teaching plan?
Correct Answer: A
Rationale: Fever is a common side effect of high-dose chemotherapy due to neutropenia and increased infection risk, and should be included in the teaching plan.
Question 4 of 5
Which symptom suggests worsening neurological status in a client with a head injury?
Correct Answer: B
Rationale: Decreased pulse rate (bradycardia) may indicate increased intracranial pressure, a sign of worsening neurological status.
Question 5 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.