NCLEX-RN
NCLEX RN Medical Surgical Questions Questions
Extract:
Question 1 of 5
A young adult client has been diagnosed with type 1 diabetes. He has an insulin drip to aid in lowering the serum blood glucose level of 600 mg/dL. He is also receiving I.V. antibiotics for a urinary tract infection. After 4 hours, the physician orders discontinuation of the insulin drip. The nurse should next?
Correct Answer: C
Rationale: Discontinuing an insulin drip without initiating subcutaneous insulin risks rebound hyperglycemia in type 1 diabetes. The nurse should inform the physician to ensure a subcutaneous insulin order is in place.
Question 2 of 5
A client with advanced Hodgkin's disease is admitted to hospice because death is imminent. The goal to address for the client is:
Correct Answer: A
Rationale: In hospice care for advanced Hodgkin's disease, the primary goal is to address fear of pain, ensuring comfort as death approaches. Fear of therapy, isolation, and social inadequacy are less relevant at this stage.
Question 3 of 5
A client has vertigo. Which of the following actions would be most appropriate for the nursing diagnosis of Risk for injury related to altered immobility and gait disturbances? Select all that apply.
Correct Answer: A,B,C,E
Rationale: Appropriate actions include assuming a safe position (e.g., sitting or lying down), preventing falls, performing vestibular exercises to improve balance, and keeping the head still during vertigo to minimize symptoms and reduce injury risk.
Question 4 of 5
The nurse should instruct the client with an ileostomy to report which of the following signs and symptoms immediately?
Correct Answer: C
Rationale: Absence of drainage from an ileostomy for 6 or more hours may indicate a blockage, requiring immediate reporting. Liquid stool and undigested food are normal, and a slightly elevated temperature is less urgent unless persistent. CN: Physiological adaptation; CL: Synthesize
Question 5 of 5
The nurse is admitting a client with acute appendicitis to the emergency department. The client has abdominal pain of 10 on a pain scale of 1 to 10. The client will be going to surgery as soon as possible. The nurse should:
Correct Answer: C
Rationale: The client with acute appendicitis should be placed on NPO status in preparation for surgery to prevent aspiration risk. Narcotics may mask symptoms, a recumbent position is not specific, and heat could worsen inflammation. CN: Physiological adaptation; CL: Synthesize