NCLEX-RN
NCLEX RN Questions Medical Surgical Nursing Questions
Extract:
Question 1 of 5
The client with a hearing aid does not seem to be able to hear the nurse. The nurse should do which of the following?
Correct Answer: D
Rationale: Checking the hearing aid's placement is the first step, as improper placement or a low battery is a common cause of ineffective hearing aid function.
Question 2 of 5
The client with a laryngectomy is being discharged. The nurse should determine that the client understands to do which of the following self-care measures? Select all that apply.
Correct Answer: A,B,C
Rationale: Self-care measures include home humidification to keep the airway moist, using a stoma shield during bathing to prevent water entry, and consuming 2-3 L/day of fluids to maintain hydration. Spicy foods and low-fiber diets are not typically restricted.
Question 3 of 5
Which of the following findings would most likely indicate the presence of a respiratory infection in a client with asthma?
Correct Answer: A
Rationale: A productive cough with yellow sputum suggests a respiratory infection, which can exacerbate asthma. Wheezing, chest tightness, and tachypnea are typical asthma symptoms, not specific to infection.
Question 4 of 5
The client with a hearing aid does not seem to be able to hear the nurse. The nurse should do which of the following?
Correct Answer: D
Rationale: Checking the hearing aid's placement is the first step, as improper placement or a low battery is a common cause of ineffective hearing aid function.
Question 5 of 5
A client is receiving fluid replacement with Lactated Ringer's after 40% of his body was burned 10 voluto hours ago. The assessment reveals: temperature 36.2°C; heart rate 122; blood pressure 84/42; CVP 2 mm Hg; and urine output 25 mL for the last 2 hours. The I.V. rate is currently at 375 mL/hour. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse calls the healthcare provider with the recommendation for:
Correct Answer: C
Rationale: Low blood pressure, high heart rate, low CVP, and inadequate urine output indicate hypovolemia. Increasing the I.V. rate is appropriate to improve fluid resuscitation, as per burn fluid management protocols.