NCLEX-RN
NCLEX RN Medical Surgical Questions and Answers Questions
Extract:
Question 1 of 5
An older adult takes two 81 mg aspirin tablets daily to prevent a heart attack. The client reports having a constant 'ringing' in both ears. How should the nurse respond to the client's comment?
Correct Answer: D
Rationale: Aspirin, even at low doses, can cause tinnitus (ringing in the ears) as a side effect. The nurse should explain this potential link and advise consulting the physician.
Question 2 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 3 of 5
Three weeks after the client has had an ileostomy, the nurse is following up with instruction about using a skin barrier around the stoma at all times. The client has been applying the skin barrier correctly when:
Correct Answer: C
Rationale: Correct application of a skin barrier is indicated by no skin irritation around the stoma, as the barrier protects the peristomal skin. Odor, hydration, and pouch change frequency are not direct indicators of proper barrier use. CN: Physiological adaptation; CL: Evaluate
Question 4 of 5
A nurse has two clients that have an order to receive a blood transfusion of packed red blood cells at the same time. The first client's blood pressure dropped from the preoperative value of 120/80 mm Hg to a postoperative value of 100/50. The second client is 58 years old and is hospitalized because he developed dehydration and anemia following pneumonia. After checking the patency of their I.V. lines and vital signs, which should the nurse do next?
Correct Answer: C
Rationale: The first client's significant blood pressure drop (120/80 to 100/50) indicates potential hypovolemia or bleeding, making their transfusion a priority to restore volume and oxygen-carrying capacity. The second client's condition is less urgent. The nurse should call for and hang the first client's transfusion first.
Question 5 of 5
The nurse is caring for a client with Crohn's disease who reports frequent nighttime diarrhea. Which intervention should the nurse prioritize?
Correct Answer: D
Rationale: Providing a bedside commode is the priority to ensure safety and comfort for a client with frequent nighttime diarrhea due to Crohn's disease. Antidiarrheals may be used but require careful monitoring, a high-fiber diet may worsen symptoms, and meal timing is less impactful. CN: Physiological adaptation; CL: Synthesize