NCLEX-RN
NCLEX RN Medical Surgical Questions Questions
Extract:
Question 1 of 5
The nurse finds the apical impulse below the fifth intercostal space. The nurse suspects:
Correct Answer: B
Rationale: An apical impulse below the fifth intercostal space suggests left ventricular enlargement, common in heart failure due to ventricular dilation.
Question 2 of 5
A nurse is teaching a 62-year-old female who has had a left modified radical mastectomy with axillary node dissection about lymphedema. The nurse should tell the client that lymphedema occurs:
Correct Answer: C
Rationale: Lymphedema can occur at any time after mastectomy with lymph node dissection due to disrupted lymphatic drainage, or it may never occur.
Question 3 of 5
A daughter is concerned that her mother is in denial when discussing her diagnosis of breast cancer because she sometimes says that breast cancer isn't that serious and changes the subject. The nurse informs the daughter that denial can be a healthy defense mechanism if it is used:
Correct Answer: D
Rationale: Denial can be healthy if it allows the client to maintain normal roles (e.g., as a mother) while gradually processing the diagnosis, as long as it doesn't interfere with treatment.
Question 4 of 5
A client refuses to remove a religious necklace before surgery despite hospital policy. The nurse's best response is:
Correct Answer: B
Rationale: Taping the necklace securely respects the client's beliefs while ensuring safety by preventing the item from interfering with the surgical field.
Question 5 of 5
Although all of the following measures might be useful in reducing the visual disability of a client with adult macular degeneration (AMD), which measure should the nurse teach the client primarily as a safety precaution?
Correct Answer: B
Rationale: Placing personal items on the sighted side enhances safety by ensuring the client can see and access items easily, reducing the risk of falls or accidents.