NCLEX-RN
NCLEX RN Medical Surgical Questions and Answers Questions
Extract:
Question 1 of 5
The nurse is assessing a client post-laminectomy for complications. Which finding requires immediate action?
Correct Answer: B
Rationale: Clear drainage may indicate a cerebrospinal fluid leak, a critical complication requiring urgent intervention.
Question 2 of 5
Which of the following nursing interventions is appropriate for a client with an increased intracranial pressure (ICP) of 20 mm Hg?
Correct Answer: B
Rationale: Low-dose barbiturates can reduce cerebral metabolism and ICP, making them appropriate in some cases under medical supervision. Warming blankets increase metabolic demand, hyperventilation is no longer routinely recommended due to risks of cerebral vasoconstriction, and fluid restriction is not standard for ICP management unless specifically indicated.
Question 3 of 5
The nurse sees a client walking in the hallway who begins to have a seizure. The nurse should do which of the following in priority order?
Order the Items
Source Container
Correct Answer: C,A,B,D
Rationale: The priority order is: 1) Ease the client to the floor to prevent injury (
C); 2) Maintain a patent airway to ensure oxygenation (
A); 3) Record seizure activity for accurate reporting (
B); 4) Obtain vital signs post-seizure to assess stability (
D).
Question 4 of 5
Which nursing intervention has been found to be the most effective means of preventing plantar flexion in a client who has had a stroke with residual paralysis?
Correct Answer: A
Rationale: A firm footboard maintains the foot in a neutral position, preventing plantar flexion contractures. Repositioning, shoes, or massage are less effective for this specific purpose.
Question 5 of 5
Which of the following is not a typical clinical manifestation of multiple sclerosis (MS)?
Correct Answer: B
Rationale: Sudden bursts of energy are not typical in MS, which often causes fatigue. Double vision, weakness, and tremors are common due to demyelination affecting vision, motor, and coordination.