NCLEX-RN
NCLEX RN Medical Surgical Questions and Answers 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
A client with rib fractures and a pneumothorax has a chest tube inserted that is connected to a water-seal chest tube drainage system. The nurse notes that the fluid in the water-seal column is fluctuating with each breath that the client takes. What is the significance of this fluctuation?
Correct Answer: C
Rationale: Fluctuation in the water-seal column with breathing indicates a patent chest tube system, reflecting pleural pressure changes. Obstruction, emphysema, or leaks would show different signs.
Question 3 of 5
The nurse is caring for a client with Crohn's disease who reports frequent nighttime diarrhea. Which intervention should the nurse prioritize?
Correct Answer: D
Rationale: Providing a bedside commode is the priority to ensure safety and comfort for a client with frequent nighttime diarrhea due to Crohn's disease. Antidiarrheals may be used but require careful monitoring, a high-fiber diet may worsen symptoms, and meal timing is less impactful. CN: Physiological adaptation; CL: Synthesize
Question 4 of 5
The American Heart Association (AHA) guidelines urge greater availability of automated external defibrillators (AEDs) and people trained to use them. AEDs are used in cardiac arrest situations for:
Correct Answer: C
Rationale: AEDs are used for early defibrillation in ventricular fibrillation or pulseless ventricular tachycardia, as these are shockable rhythms that can be corrected to restore cardiac function.
Question 5 of 5
The nurse teaches the client with an ileal conduit measures to prevent a urinary loss. Which of the following measures would be most effective?
Correct Answer: B
Rationale: Maintaining high fluid intake (2,000-3,000 mL) prevents urinary stasis and infection, the most effective measure for reducing urinary loss risk.