NCLEX-RN
Medical Surgical NCLEX RN Questions
Extract:
Question 1 of 5
Eight hours after surgery, a client has a distended bladder and is unable to void. Which of the following is the most appropriate nursing action?
Correct Answer: A
Rationale: A distended bladder and inability to void suggest urinary retention, common post-surgery. Inserting a straight catheter relieves the bladder and prevents complications like overdistension.
Question 2 of 5
A client with lung cancer is being cared for by his wife at home. His pain is increasing in severity. The nurse recognizes that teaching has been effective when the wife does which of the following? Select all that apply.
Correct Answer: A,B,D,F
Rationale: Effective pain management includes around-the-clock long-acting opioids (
A), immediate-release opioids for breakthrough pain (
B), non-pharmacologic methods like music or heat/cold (
D), and using a pain scale to assess effectiveness (F). Avoiding long-acting opioids (
C) or substituting acetaminophen (E) is not appropriate for severe cancer pain.
Question 3 of 5
What is the priority intervention for a client with a suspected stroke?
Correct Answer: C
Rationale: Monitoring neurological status is the priority to detect changes and guide timely stroke intervention.
Question 4 of 5
The nurse explains to the client with pain that the purpose of biofeedback is to enable him to exert control over his physiologic processes by:
Correct Answer: D
Rationale: Biofeedback translates physiological signals (e.g., heart rate) into observable forms, allowing the client to control them consciously. It does not involve electrical shocks, therapist interpretation, or direct electrical regulation.
Question 5 of 5
A client with colon cancer undergoes surgical removal of a segment of colon and creation of a sigmoid colostomy. What assessments by the nurse indicate the client is developing complications within the first 24 hours? Select all that apply.
Correct Answer: B,C,D
Rationale: A dusky stoma (
B) indicates poor blood supply, no drainage (
C) suggests obstruction or dysfunction, and fever (
D) may indicate infection, all of which are complications post-colostomy. Coarse breath sounds (
A) and decreased bowel sounds (E) are not necessarily indicative of immediate complications.