NCLEX-RN
NCLEX RN Med Surg Questions Questions
Extract:
Question 1 of 5
The client asks the nurse, 'Is it really possible to lead a normal life with an ileostomy?' Which action by the nurse would be the most effective to address this question?
Correct Answer: C
Rationale: Arranging for a person with an ostomy to visit provides a relatable, firsthand perspective, addressing the client's concerns about normalcy effectively. Clergy, postponing concerns, or notifying the surgeon are less direct or supportive. CN: Psychosocial adaptation; CL: Synthesize
Question 2 of 5
Which of the following activities indicates that the client with cancer is adapting well to body image changes?
Correct Answer: D
Rationale: Volunteering in a client-to-client program indicates positive adaptation to body image changes, as it reflects confidence and engagement with others despite physical changes.
Question 3 of 5
A client is receiving an I.V. infusion of 5% dextrose in water (D5W). The skin around the I.V. insertion site is red, warm to touch, and painful. The nurse should first:
Correct Answer: C
Rationale: Redness, warmth, and pain at the I.V. site indicate phlebitis or infiltration. The first action is to discontinue the I.V. to prevent further tissue damage. Changing fluids, applying a compress, or giving acetaminophen does not address the immediate issue.
Question 4 of 5
The right hand of a client with multiple sclerosis trembles severely whenever she attempts a purposeful act, such as picking up her coffee cup or buttoning her dress. Which is the best legal documentation in nurses' notes of the chart for this client assessment?
Correct Answer: D
Rationale: The most detailed and accurate documentation is: "Slight shaking of right hand increases to severe tremor when client tries to button her clothes or drink from a cup," as it describes the intention tremor specifically and legally.
Question 5 of 5
The nurse should include which of the following instructions when developing a teaching plan for a client who is receiving isoniazid and rifampin (Rifamate) for treatment of tuberculosis?
Correct Answer: D
Rationale: Limiting alcohol intake prevents hepatotoxicity, a risk with isoniazid and rifampin. Antacids may reduce absorption. Doubling doses is dangerous. Dairy intake is unrelated.