NCLEX-RN
NCLEX RN Medical Surgical Questions Questions
Extract:
Question 1 of 5
After a thoracotomy, the nurse instructs the client to perform deep-breathing exercises. Which of the following is an expected outcome of these exercises?
Correct Answer: D
Rationale: Deep breathing expands alveoli, increasing lung surface for ventilation and preventing atelectasis post-thoracotomy. It does not elevate the diaphragm, increase blood flow, or control airflow to prevent hyperinflation.
Question 2 of 5
A daughter is concerned that her mother is in denial when discussing her diagnosis of breast cancer because she sometimes says that breast cancer isn't that serious and changes the subject. The nurse informs the daughter that denial can be a healthy defense mechanism if it is used:
Correct Answer: D
Rationale: Denial can be healthy if it allows the client to maintain normal roles (e.g., as a mother) while gradually processing the diagnosis, as long as it doesn't interfere with treatment.
Question 3 of 5
When assessing the lower extremities of a client with peripheral vascular disease (PVD), the nurse notes bilateral ankle edema. The edema is related to:
Correct Answer: C
Rationale: Bilateral ankle edema in PVD is often due to increased venous pressure from venous insufficiency or right-sided heart failure, which impairs venous return and causes fluid to pool in the lower extremities. Decreased blood volume or increased muscular activity does not cause edema, and arterial pressure is not directly related.
Question 4 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
Question 5 of 5
Following abdominal surgery, a client refuses to deep breathe and cough every 2 hours as ordered. The nurse should do which of the following first?
Correct Answer: C
Rationale: Assessing the client's reasons for refusal identifies barriers (e.g., pain, fear), allowing tailored interventions to encourage compliance with deep-breathing exercises.