NCLEX-RN
NCLEX RN Medical Surgical Questions and Answers Questions
Extract:
Question 1 of 5
As a result of a gastric resection, the client is at risk for development of dumping syndrome. The nurse should prepare a plan of care for this client based on knowledge that this problem stems primarily from which of the following gastrointestinal changes?
Correct Answer: B
Rationale: Dumping syndrome occurs due to rapid emptying of stomach contents into the small intestine, causing osmotic and vasomotor symptoms. The other options are not primary causes.
Question 2 of 5
The nurse is planning care for a client on complete bed rest. The plan of care should include all except which of the following:
Correct Answer: D
Rationale: Maintaining the client in the supine position is not recommended, as it promotes stasis and pressure ulcers. Turning every 2 hours, range-of-motion exercises, and TED hose prevent complications like thrombophlebitis and skin breakdown during bed rest.
Question 3 of 5
A client who has undergone outpatient nasal surgery is ready for discharge and has nasal packing in place. Which of the following discharge instructions would be appropriate for the client?
Correct Answer: A
Rationale: Avoiding the Valsalva maneuver (e.g., straining) prevents increased pressure that could dislodge packing or cause bleeding. Aspirin increases bleeding risk.
Tooth brushing is safe with care. Heat may increase swelling; cold is preferred.
Question 4 of 5
The nurse is developing a plan to teach a client deep-breathing exercises to expand collapsed alveoli and prevent postoperative atelectasis and pneumonia. Which of the following steps should be included? Select all that apply.
Correct Answer: A,B,C,D
Rationale: Splinting the incision (
A), slow nasal inhalation with pursed-lip exhalation (
B), holding the breath (
C), and repeating 5-10 times hourly (
D) are correct steps for deep-breathing exercises to prevent atelectasis. Closing one nostril (E) is not part of this technique.
Question 5 of 5
The most effective measure the nurse can use to prevent wound infection when changing a client's dressing after coronary artery bypass surgery is to:
Correct Answer: A
Rationale: Hand-washing is the most effective measure to prevent wound infection, as it reduces the risk of introducing pathogens during dressing changes.