NCLEX-RN
Med Surg RN NCLEX Questions Questions
Extract:
Question 1 of 5
On the fourth day after surgery, a client has a postoperative wound infection. Which of the following should the nurse assess? Select all that apply.
Correct Answer: B,C,D,E
Rationale: Signs of wound infection include redness/swelling (
B), fever (
C), pain (
D), and warmth (E). A WBC of 10,000/mm³ (
A) is normal and not indicative of infection.
Question 2 of 5
A female client who has a urinary diversion tells the nurse, 'This urinary pouch is embarrassing. Everyone will know that I'm not normal. I don't see how I can go out in public anymore.' The most appropriate nursing diagnosis for this client is:
Correct Answer: D
Rationale: The client's statement reflects distress about the urinary diversion's impact on her appearance and social life, indicating a disturbed body image.
Question 3 of 5
What is the purpose of sodium polystyrene sulfonate in acute renal failure?
Correct Answer: B
Rationale: Sodium polystyrene sulfonate removes potassium from the body, treating hyperkalemia.
Question 4 of 5
A client receiving vent-assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. The nurse should:
Correct Answer: B
Rationale: Cluster breathing, a sign of neurological deterioration, requires immediate physician notification for evaluation and possible intervention. Adjusting ventilator settings without medical orders is inappropriate, and simply counting the rate does not address the underlying issue.
Question 5 of 5
In the acute phase of burn injury, which pain medication would most likely be given to the client to decrease the perception of the pain?
Correct Answer: B
Rationale: Intravenous opioids are preferred in the acute phase for rapid, effective pain relief due to severe burn pain and potential impaired oral absorption.