NCLEX-RN
NCLEX RN Questions Medical Surgical Nursing Questions
Extract:
Question 1 of 5
Before abdominal surgery for an intestinal obstruction, the nurse monitors the client's urine output and finds the total output for the past 2 hours was 35 mL. The nurse then assesses the client's total intake and output over the last 24 hours and notes that he had 2,000 mL of I.V. fluid for intake, 500 mL of drainage from the nasogastric tube, and 700 mL of urine for a total output of 1,200 mL. This would indicate which of the following?
Correct Answer: D
Rationale: The low urine output (35 mL in 2 hours) and a 24-hour output (1,200 mL) less than intake (2,000 mL) suggest inadequate fluid replacement, as the body is retaining fluid or losing it through vomiting and NG drainage. Decreased renal function, pain, or obstruction extension are less directly indicated. CN: Physiological adaptation; CL: Analyze
Question 2 of 5
When performing external chest compressions on an adult during cardiopulmonary resuscitation (CPR), the rescuer should depress the sternum:
Correct Answer: C
Rationale: Depressing the sternum 1.5 to 2 inches ensures adequate compression depth for effective CPR in adults, per guidelines.
Question 3 of 5
The nurse should teach the client with an ileal conduit to prevent urine leakage when changing the appliance by using which of the following procedures?
Correct Answer: A
Rationale: Inserting a gauze wick into the stoma temporarily absorbs urine, preventing leakage during appliance changes, ensuring a dry field for secure adhesion.
Question 4 of 5
Interferon alfa-2b (Intron A) has been prescribed to treat a client with chronic hepatitis B. The nurse should assess the client for which of the following adverse effects?
Correct Answer: C
Rationale: Interferon alfa-2b commonly causes flulike symptoms (
C), such summer fever, chills, and fatigue. Retinopathy (
A), constipation (
B), and hypoglycemia (
D) are not typical adverse effects.
Question 5 of 5
The client tells the nurse that since his diagnosis of stomach cancer, he has been having trouble sleeping and is frequently preoccupied with thoughts about how his life will change. He says, 'I wish my life could stay the same.' Based on this information, which one of the following nursing diagnoses would be appropriate at this time?
Correct Answer: C
Rationale: The client's statement and symptoms suggest grieving related to the life-altering diagnosis of stomach cancer. This diagnosis best captures the emotional response to the anticipated changes.