NCLEX-RN
NCLEX RN Medical Surgical Questions and Answers Questions
Extract:
Question 1 of 5
The most effective measure the nurse can use to prevent wound infection when changing a client's dressing after coronary artery bypass surgery is to:
Correct Answer: A
Rationale: Hand-washing is the most effective measure to prevent wound infection, as it reduces the risk of introducing pathogens during dressing changes.
Question 2 of 5
A client requests a narcotic analgesic shortly after the oncoming nurse receives change-of-shift report. The nurse who is leaving reported that the client had received morphine 10 mg (IM) within the past hour. The nurse should ask the outgoing RN to do which of the following actions?
Correct Answer: A
Rationale: Validating with the outgoing RN confirms the morphine administration, ensuring safe timing of the next dose and preventing overdose.
Question 3 of 5
An older adult takes two 81 mg aspirin tablets daily to prevent a heart attack. The client reports having a constant 'ringing' in both ears. How should the nurse respond to the client's comment?
Correct Answer: D
Rationale: Aspirin, even at low doses, can cause tinnitus (ringing in the ears) as a side effect. The nurse should explain this potential link and advise consulting the physician.
Question 4 of 5
When developing a teaching plan for a client who is prescribed acetaminophen (Tylenol) for muscle pain, which information should the nurse expect to include? Select all that apply.
Correct Answer: A,B,C
Rationale: Acetaminophen is safe for aspirin allergies, does not affect platelets, and causes minimal gastric distress. It has weak anti-inflammatory effects and does not require INR monitoring.
Question 5 of 5
The nurse explains to the client with Hodgkin's disease that a bone marrow biopsy will be taken after the aspiration. What should the nurse explain about the biopsy?
Correct Answer: B
Rationale: During a bone marrow biopsy, the client feels pressure but should not experience pain due to local anesthesia. The nurse should instruct the client to report pain for additional anesthesia. The biopsy follows the aspiration, no crunch or suction pain is typical, and an incision may be made for the biopsy, not just aspiration.