NCLEX-RN
NCLEX RN Medical Surgical Questions and Answers Questions
Extract:
Question 1 of 5
The nurse is assessing a client with chronic hepatitis B who is receiving Lamivudine (Epivir). What information is most important to communicate to the physician?
Correct Answer: A
Rationale: A 3 kg weight loss in 2 days (
A) is significant and may indicate worsening liver function or fluid loss, requiring urgent physician attention. Nausea (
B), low-grade fever (
C), and fatigue (
D) are common but less critical.
Question 2 of 5
The client complains of aching, weakness, and a cramping sensation in both of his lower extremities while walking. The nurse knows that exercise enhances blood circulation and utilization of oxygen by the tissues. To promote health and maintain the client's level of activity, the nurse should suggest that the client try:
Correct Answer: D
Rationale: Riding a stationary bike is a low-impact exercise that promotes circulation and oxygen utilization without excessive strain, suitable for PVD clients with claudication. Skiing and jogging may exacerbate symptoms due to high intensity, and golfing involves prolonged standing, which is less beneficial.
Question 3 of 5
Which of the following nursing interventions would most likely promote self-care behaviors in the client with a hiatal hernia?
Correct Answer: C
Rationale: Encouraging the client to identify past instances of responsibility promotes self-efficacy and motivates self-care behaviors, which is most effective for long-term management.
Question 4 of 5
The nurse is assessing a hospitalized older client for the presence of pressure ulcers. The nurse notes that the client has a 1" × 1" area on his sacrum in which there is skin breakdown as far as the dermis. What should the nurse note on the chart?
Correct Answer: B
Rationale: A Stage II pressure ulcer involves partial-thickness skin loss extending to the dermis, matching the description of the sacral breakdown.
Question 5 of 5
To decrease intraocular pressure following cataract surgery, the nurse should instruct the client to avoid:
Correct Answer: B
Rationale: Coughing increases intraocular pressure by causing a Valsalva maneuver, which can strain the surgical site and lead to complications like hemorrhage or wound dehiscence.