NCLEX-RN
Free NCLEX RN Questions for Med Surg Questions
Extract:
Question 1 of 5
A nurse is developing a care plan for a client with hepatic encephalopathy. Which of the following are goals for the care for this client? Select all that apply.
Correct Answer: A,B
Rationale: Preventing constipation (
A) and administering lactulose (
B) reduce ammonia levels, key in managing hepatic encephalopathy. Coordination (
C) and pupil reaction (
D) are unrelated. High carbohydrates (E) and physical activity (F) are not primary goals.
Question 2 of 5
Four days after surgery for internal fixation of a C3 to C4 fracture, a nurse is moving a client from the bed to the wheelchair. The nurse is checking the wheelchair for correct features for this client. Which of the following features of the wheelchair are appropriate for the needs of this client?
Correct Answer: B,D,E
Rationale: A high back and headrest provide neck stability, firm cushions prevent pressure ulcers, and a breath-controlled chair accommodates limited upper extremity function post-C3-C4 injury. A low back or lower seat height could compromise stability or transfer safety.
Question 3 of 5
A client with acute renal failure has a low calcium level. The nurse should monitor for:
Correct Answer: A
Rationale: Low calcium can cause tetany, manifesting as muscle cramps or spasms.
Question 4 of 5
A client who had an exploratory laparotomy 3 days ago has a white blood cell (WBC) differential with a shift to the left. The nurse instructs unlicensed personnel to report which clinical manifestation?
Correct Answer: C
Rationale: A left shift in the WBC differential indicates an increase in immature neutrophils, often due to infection. An elevated temperature is a key sign of infection and should be reported promptly. Swelling, redness, and purulent drainage are also concerning but may develop later.
Question 5 of 5
The client states she does not understand what causes idiopathic thrombocytopenic purpura (ITP). The nurse provides which of the following explanations?
Correct Answer: A
Rationale: Idiopathic thrombocytopenic purpura (ITP) is an autoimmune condition where antibodies coat platelets, marking them for destruction by the spleen. This leads to a low platelet count. The liver is not primarily involved, ITP is not due to an underactive immune system, and while 'idiopathic' means the exact trigger is unknown, the autoimmune mechanism is well-established.