NCLEX-RN
NCLEX RN Medical Surgical Questions and Answers Questions
Extract:
Question 1 of 5
A nurse is providing wound care to a client 1 day after the client underwent an appendectomy. A drain was inserted into the incisional site during surgery. Which action should the nurse perform when providing wound care?
Correct Answer: D
Rationale: When providing wound care, the nurse should clean the area around the drain moving away from the drain to prevent introducing pathogens into the wound. Leaving the incision open, removing the drain, or irrigating are not appropriate without specific orders. CN: Physiological adaptation; CL: Synthesize
Question 2 of 5
The nurse should instruct a client who has been diagnosed with vasospastic disorder (Raynaud's phenomenon) to:
Correct Answer: C
Rationale: Wearing gloves when handling ice or frozen foods prevents cold-induced vasospasm in Raynaud's. Cold water worsens symptoms, light garments are insufficient in cold temperatures, and living in a cold climate increases episode frequency.
Question 3 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 in hepatic encephalopathy. Coordination (
C) and pupil reaction (
D) are less relevant. High carbohydrates (E) are not specific, and physical activity (F) may be limited.
Question 4 of 5
The nurse is assessing a hospitalized older client for the presence of pressure ulcers. The nurse notes that the client has a 1" × 1" area on his sacrum in which there is skin breakdown as far as the dermis. What should the nurse note on the chart?
Correct Answer: B
Rationale: A Stage II pressure ulcer involves partial-thickness skin loss extending to the dermis, matching the description of the sacral breakdown.
Question 5 of 5
A client who has undergone a subtotal thyroidectomy is subject to complications in the first 48 hours after surgery. The nurse should obtain and keep at the bedside equipment to:
Correct Answer: D
Rationale: Tracheotomy equipment is essential due to the risk of airway obstruction from swelling or hemorrhage post-thyroidectomy.