Questions 108

NCLEX-RN

NCLEX-RN Test Bank

Med Surg RN NCLEX Questions Questions

Extract:


Question 1 of 5

In the oliguric phase of acute renal failure, the nurse should assess the client for:

Correct Answer: A

Rationale: Pulmonary edema is a risk in the oliguric phase due to fluid overload from reduced urine output.

Question 2 of 5

What diet should be implemented for a client who is in the early stages of cirrhosis?

Correct Answer: A

Rationale: A high-calorie, high-carbohydrate diet (
A) supports energy needs in early cirrhosis without overloading the liver. High-protein (
B) risks encephalopathy, low-fat, low-protein (
C) is too restrictive, and low-sodium (
D) is for later stages with ascites.

Question 3 of 5

A nurse receives the taped change-of-shift report for assigned clients and prioritizes client rounds. In what order should the nurse assess these clients?

Order the Items

Source Container

A client with an endotracheal tube transferred out of the intensive care unit that day.
A client with type 2 diabetes who had a cerebrovascular accident 4 days ago.
A client with cellulitis of the left lower extremity with a fever of 100.8°F (38.2°C).
A client receiving D5W I.V. at 125 mL/hour with 75 mL remaining.

Correct Answer: A,C,B,D

Rationale: The client with a new endotracheal tube (
A) is highest priority due to airway risk. The febrile client with cellulitis (
C) is next for infection monitoring. The stroke client (
B) is stable 4 days post-event. The I.V. fluid client (
D) is lowest priority.

Question 4 of 5

The nurse is obtaining a health history from a client who has a sliding hiatal hernia associated with reflux. The nurse should ask the client about the presence of which of the following symptoms?

Correct Answer: A

Rationale: Heartburn is a hallmark symptom of a sliding hiatal hernia with reflux, caused by stomach acid refluxing into the esophagus.

Question 5 of 5

The client with glaucoma is scheduled for a hip replacement. Which of the following orders would require clarification before the nurse carries it out?

Correct Answer: B

Rationale: Atropine sulfate can increase intraocular pressure, which is contraindicated in glaucoma. The nurse should clarify this order to ensure it is safe for the client.

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