NCLEX-RN
Medical Surgical Nursing NCLEX RN Questions Questions
Extract:
Question 1 of 5
Good dental care is an important measure in reducing the risk of endocarditis. A teaching plan to promote good dental care in a client with mitral stenosis should include demonstration of the proper use of:
Correct Answer: D
Rationale: Dental floss removes plaque and debris, reducing the risk of oral infections that could lead to endocarditis in mitral stenosis.
Question 2 of 5
Because a client has a Thomas splint, the nurse should assess the client regularly for which of the following?
Correct Answer: A
Rationale: The Thomas splint can cause pressure in the groin, requiring regular skin assessments to prevent breakdown.
Question 3 of 5
A client with peripheral vascular disease has chronic, severe pretibial and ankle edema bilaterally. Because the client is on complete bed rest and circulation is compromised, one goal is to maintain tissue integrity. Which of the following interventions will help achieve this outcome?
Correct Answer: C
Rationale: Turning the client every 1 to 2 hours prevents pressure ulcers by relieving pressure on dependent areas, promoting circulation, and maintaining skin integrity in a client with PVD and edema on bed rest. Pain medication, fluids, and hygiene are important but do not directly address tissue integrity.
Question 4 of 5
Which complication should the nurse monitor for in a client with a new ileal conduit?
Correct Answer: A
Rationale: Stoma prolapse is a potential complication of an ileal conduit, requiring surgical correction if severe.
Question 5 of 5
For a client with rib fractures and a pneumothorax, the physician prescribes morphine sulfate, 1 to 2 mg/hour, given I.V. as needed for pain. The nursing care goal is to provide adequate pain control so that the client can breathe effectively. Which of the following outcomes would indicate successful achievement of this goal?
Correct Answer: A
Rationale: A pain rating of 0 indicates adequate pain control, enabling effective breathing. A respiratory rate of 26 is elevated, and a PaO2 of 70 mm Hg suggests mild hypoxemia, neither confirming pain control.