NCLEX-RN
NCLEX RN Med Surg Questions Questions
Extract:
Question 1 of 5
One goal in caring for a client with arterial occlusive disease is to promote vasodilation in the affected extremity. To achieve this goal, the nurse encourages the client to:
Correct Answer: C
Rationale: Stopping smoking promotes vasodilation by reducing nicotine-induced vasoconstriction and improving endothelial function, critical in arterial occlusive disease. Applying heat risks burns in ischemic tissue, elevating legs worsens arterial flow, and jogging may be contraindicated due to claudication.
Question 2 of 5
A client has a Pearson attachment on the traction setup. What is the purpose of this attachment?
Correct Answer: A
Rationale: The Pearson attachment supports the lower leg, maintaining alignment in balanced suspension traction.
Question 3 of 5
When a client is receiving a cephalosporin, the nurse must monitor the client for which of the following?
Correct Answer: A
Rationale: Cephalosporins can rarely cause drug-induced hemolytic anemia by triggering an immune response that destroys red blood cells. The nurse should monitor for signs such as jaundice, dark urine, or a drop in hemoglobin. Purpura, infectious emboli, and ecchymosis are not commonly associated with cephalosporin use.
Question 4 of 5
The client admitted with peripheral vascular disease (PVD) asks the nurse why her legs hurt when she walks. The nurse bases a response on the knowledge that the main characteristic of PVD is:
Correct Answer: A
Rationale: The hallmark of PVD is decreased blood flow due to arterial narrowing from atherosclerosis or other occlusive processes. This reduced flow causes ischemia, leading to claudication (pain during walking) that is relieved by rest. Increased or slow blood flow and thrombus formation are not the primary characteristics.
Question 5 of 5
A client with rheumatoid arthritis states, 'I can't do my household chores without becoming tired. My knees hurt whenever I walk.' Which nursing diagnosis would be most appropriate?
Correct Answer: A
Rationale: The client's symptoms of fatigue and knee pain directly contribute to activity intolerance, making this the most appropriate nursing diagnosis.