NCLEX-RN
Medical Surgical Nursing NCLEX RN Questions Questions
Extract:
Question 1 of 5
At 8 a.m., the nurse reviews the amount of T-tube drainage for a client who underwent an open cholecystectomy yesterday. After reviewing the output record (see chart), the nurse should:
Correct Answer: C
Rationale: The T-tube should drain approximately 300 to 500 mL in the fi rst 24 hours and after 3 to 4 days the amount should decrease to less than 200 mL in 24 hours. With the sudden decrease in drainage at 8 a.m., the nurse should immediately assess the tube for obstruction of flow that can be caused by kinks in the tube or the client lying on the tube. Drainage color must also be assessed for signs of bleeding. The tube should not be irrigated or clamped without an order.
Question 2 of 5
Which of the following interventions is most appropriate for a client who has stomatitis?
Correct Answer: D
Rationale: Stomatitis involves inflammation of the oral mucosa, often causing pain and sensitivity. A soft, bland diet is most appropriate as it minimizes irritation and discomfort during eating. Hot tea, antiseptic mouthwash, and electric toothbrushes can exacerbate irritation or pain in the inflamed oral tissues.
Question 3 of 5
What should the nurse teach a client about how to avoid the dumping syndrome? Select all that apply.
Correct Answer: C,D,E
Rationale:
To avoid dumping syndrome, clients should reduce fluids with meals, ensure adequate protein and fat, and eat in a relaxing environment. Three meals a day and high-carbohydrate foods can exacerbate symptoms.
Question 4 of 5
A client post-cystectomy is at risk for:
Correct Answer: A
Rationale: Cystectomy may impair vitamin B12 absorption due to ileum resection.
Question 5 of 5
A client who had a cholecystectomy has a biliary drainage tube in place. Which of the following colors of the drainage is expected?
Correct Answer: D
Rationale: Biliary drainage after cholecystectomy is typically green due to bile, which is produced by the liver and stored in the gallbladder.