NCLEX-RN
Med Surg RN NCLEX Questions Questions
Extract:
Question 1 of 5
Prevention of skin breakdown and maintenance of skin integrity among older clients is important because they are at greater risk secondary to:
Correct Answer: B
Rationale: Older adults have reduced pressure sensation due to thinner skin and nerve changes, increasing the risk of skin breakdown and pressure ulcers.
Question 2 of 5
When beginning I.V. erythropoietin (Epogen, Procrit) therapy, the nurse should do which of the following? Select all that apply.
Correct Answer: A,C,D,F
Rationale: For IV erythropoietin therapy, the nurse should check hemoglobin levels to monitor response and prevent overcorrection, keep multidose vials refrigerated to maintain stability, administer without mixing with other medications to avoid interactions, and educate about avoiding hazardous activities due to potential side effects like dizziness. Shaking the vial can denature the protein, and dose adjustments are typically based on hematologic response, not blood pressure.
Question 3 of 5
A client with a hemorrhagic stroke is slightly agitated, heart rate is 118, respirations are 22, bilateral rhonchi are auscultated, SpO2 is 94%, blood pressure is 144/88, and oral secretions are noted. What order of interventions should the nurse follow when suctioning the client to prevent increased intracranial pressure (ICP) and maintain adequate cerebral perfusion?
Order the Items
Source Container
Correct Answer: B,D,A,C
Rationale: The correct order is: 1) Hyperoxygenate to prevent hypoxia (
B); 2) Provide sedation to reduce agitation and ICP spikes (
D); 3) Suction the airway to clear secretions (
A); 4) Suction the mouth to remove residual secretions (
C). This sequence minimizes ICP increases and ensures oxygenation.
Question 4 of 5
The client asks the nurse to explain what it means that his Hodgkin's disease is diagnosed at stage 1A. Which of the following describes the involvement of the disease?
Correct Answer: A
Rationale: Stage 1A Hodgkin's disease indicates involvement of a single lymph node region without B symptoms (fever, night sweats, weight loss). Higher stages involve multiple nodes or extralymphatic sites.
Question 5 of 5
A 56-year-old female with lung cancer is undergoing a thoracentesis. Which of the following outcomes of the procedure are expected? Select all that apply.
Correct Answer: B,C,D
Rationale: Thoracentesis diagnoses underlying disease (
B), palliates symptoms like dyspnea (
C), and relieves acute respiratory distress (
D). It does not treat recurrent effusions or remove cancer cells.