NCLEX-RN
NCLEX RN Med Surg Questions Questions
Extract:
Question 1 of 5
During an initial assessment of a client diagnosed with vasospastic disorder (Raynaud's phenomenon), the nurse notes a sudden color change to white in the fingers. The nurse should first assess:
Correct Answer: B
Rationale: A sudden color change to white in Raynaud's indicates vasospasm. Assessing the radial pulse first confirms whether blood flow is present despite the vasospasm, guiding further action. Cyanosis, SpO2, and blood pressure are secondary, as pulse assessment is more immediate and specific.
Question 2 of 5
A client with an ileal conduit reports a bulging stoma. The nurse suspects:
Correct Answer: B
Rationale: A bulging stoma suggests a parastomal hernia, a complication requiring evaluation.
Question 3 of 5
A client has advanced cirrhosis of the liver. The client's spouse asks the nurse why his abdomen is swollen, making it very difficult for him to fasten his pants. How should the nurse respond to provide the most accurate explanation of the disease process?
Correct Answer: D
Rationale: Cirrhosis causes portal hypertension and hypoalbuminemia, leading to ascites (
D). Salt intake (
A) may worsen but isn't the primary cause. Ankle edema (
B) and diuretics (
C) are secondary factors.
Question 4 of 5
A 21-year-old male client is transported by ambulance to the emergency department after a serious automobile accident. He complains of severe pain in his right chest where he struck the steering wheel. Which is the primary client goal at this time?
Correct Answer: B
Rationale: Maintaining adequate oxygenation is the primary goal in chest trauma to prevent hypoxia from pneumothorax or hemothorax. Anxiety, pain, and volume are secondary priorities.
Question 5 of 5
The nurse is caring for a client who has just had an upper GI endoscopy. The client's vital signs must be taken every 30 minutes for 2 hours after the procedure. The nurse assigns an unlicensed nursing personnel (UAP) to take the vital signs. One hour later, the UAP reports the client, who was previously afebrile, has developed a temperature of 101.8°F (38.8°C). What should the nurse do in response to this reported assessment data?
Correct Answer: A
Rationale: A sudden fever after an upper GI endoscopy may indicate a serious complication, such as perforation, requiring immediate nursing assessment. The other options delay appropriate intervention or do not address the potential severity of the situation.