NCLEX-RN
Medical Surgical NCLEX RN Questions
Extract:
Question 1 of 5
A nurse is planning care for a client who underwent a percutaneous needle biopsy of the kidney. What should the nurse plan to do immediately after the biopsy? Select all that apply.
Correct Answer: A,C,D
Rationale: Assessing the biopsy site, urine for hematuria, and placing the client prone help monitor for bleeding and promote hemostasis post-biopsy.
Question 2 of 5
When admitting a client with a fractured extremity, the nurse should first focus the assessment on which of the following?
Correct Answer: C
Rationale: Assessing distal to the fracture checks for neurovascular compromise, a priority to prevent complications.
Question 3 of 5
The client with acute leukemia and the health care team establish mutual client outcomes of improved tidal volume and activity tolerance. Which measure would be least likely to promote outcome achievement?
Correct Answer: C
Rationale: Improving tidal volume and activity tolerance requires active movement to enhance lung expansion and stamina. Ambulating, sitting up, and using a stationary bicycle promote these outcomes. Lying in bed, even with deep breaths, is passive and least effective.
Question 4 of 5
Eight hours after surgery, a client has a distended bladder and is unable to void. Which of the following is the most appropriate nursing action?
Correct Answer: A
Rationale: A distended bladder and inability to void suggest urinary retention, common post-surgery. Inserting a straight catheter relieves the bladder and prevents complications like overdistension.
Question 5 of 5
When receiving a client from the postanesthesia care unit after a splenectomy, which should the nurse assess after obtaining vital signs?
Correct Answer: C
Rationale: After a splenectomy, the nurse should assess the dressing for signs of bleeding, as the spleen is highly vascular, and postoperative hemorrhage is a risk. Nasogastric drainage, urinary output, and pain are assessed later, but the dressing is the priority to detect complications.