NCLEX-RN
NCLEX RN Medical Surgical Questions and Answers Questions
Extract:
Question 1 of 5
In assessing a client in the early stage of chronic lymphocytic leukemia (CLL), the nurse should determine if the client has:
Correct Answer: A
Rationale: Early-stage CLL is often asymptomatic but may present with enlarged, painless lymph nodes due to lymphocyte accumulation. Headache, gum hyperplasia, and weight loss are not typical early findings.
Question 2 of 5
The most effective measure the nurse can use to prevent wound infection when changing a client's dressing after coronary artery bypass surgery is to:
Correct Answer: A
Rationale: Hand-washing is the most effective measure to prevent wound infection, as it reduces the risk of introducing pathogens during dressing changes.
Question 3 of 5
The nurse is developing a plan to teach a client deep-breathing exercises to expand collapsed alveoli and prevent postoperative atelectasis and pneumonia. Which of the following steps should be included? Select all that apply.
Correct Answer: A,B,C,D
Rationale: Splinting the incision (
A), slow nasal inhalation with pursed-lip exhalation (
B), holding the breath (
C), and repeating 5-10 times hourly (
D) are correct steps for deep-breathing exercises to prevent atelectasis. Closing one nostril (E) is not part of this technique.
Question 4 of 5
The nurse is assessing a client with chronic hepatitis B who is receiving Lamivudine (Epivir). What information is most important to communicate to the physician?
Correct Answer: A
Rationale: A 3 kg weight loss in 2 days (
A) is significant and may indicate worsening liver function or fluid loss, requiring urgent physician attention. Nausea (
B), low-grade fever (
C), and fatigue (
D) are common but less critical.
Question 5 of 5
Glulisine (Apidra) insulin is ordered to be administered to a client before each meal. To assist the day-shift nurse who is receiving the report, the night-shift nurse gives the morning dose of glulisine. When the day-shift nurse goes to the room of the client who requires glulisine, the nurse finds that the client is not in the room. The client's roommate tells the nurse that the client 'went for a test.' What should the nurse do next?
Correct Answer: A
Rationale: Glulisine is rapid-acting insulin, and the client must eat within 15 minutes to prevent hypoglycemia. The nurse should locate the client and provide juice to counteract potential hypoglycemia.