NCLEX-RN
NCLEX RN Medical Surgical Questions Questions
Extract:
Question 1 of 5
A Stage II pressure ulcer is characterized by:
Correct Answer: C
Rationale: Stage II pressure ulcers cause pain due to partial-thickness skin loss and exposed nerve endings. Redness is Stage I, and necrosis is Stage III or IV.
Question 2 of 5
The nurse assesses a client with a below-knee amputation for prosthetic fitting. Which finding indicates readiness for a prosthesis?
Correct Answer: C
Rationale: A healed incision without drainage is essential for safe prosthetic fitting to prevent skin breakdown.
Question 3 of 5
A client has an adrenal tumor and is scheduled for a bilateral adrenalectomy. During preoperative teaching, the nurse teaches the client how to do deep breathing exercises after surgery by telling the client to:
Correct Answer: B
Rationale: Holding the abdomen with a pillow during deep breathing reduces pain and supports the surgical site post-adrenalectomy.
Question 4 of 5
What is the nurse's best response to a client with MS experiencing spasticity?
Correct Answer: B
Rationale: Teaching stretching exercises helps manage spasticity in multiple sclerosis.
Question 5 of 5
A client from a Mediterranean country is admitted with thalassemia, jaundice, splenomegaly, and hepatomegaly. Which of the following should be the primary focus of nursing care for this client?
Correct Answer: C
Rationale: Thalassemia, a hemolytic anemia, causes increased cardiac workload due to chronic anemia and tissue hypoxia. Promoting rest is the primary focus to decrease cardiac demands and prevent complications like heart failure. While client preferences, nutrition, and emotional support are important, reducing cardiac strain is critical.