NCLEX-RN
NCLEX RN Med Surg Questions Questions
Extract:
Question 1 of 5
The nurse is assessing a client with dark skin for presence of a Stage I pressure ulcer. The nurse should:
Correct Answer: C
Rationale: In dark skin, Stage I pressure ulcers appear as darker areas compared to surrounding tissue, due to persistent redness or discoloration.
Question 2 of 5
The nurse is assessing a client with anemia. In order to plan nursing care, the nurse should focus the assessment on which of the following?
Correct Answer: C
Rationale: Cold intolerance is a common symptom of anemia due to reduced oxygen-carrying capacity, and assessing it helps plan supportive care.
Question 3 of 5
A client is about to have a tympanoplasty, and asks the nurse what the surgical procedure involves. The nurse begins the conversation by:
Correct Answer: A
Rationale: Assessing the client's current understanding allows the nurse to tailor education to the client's knowledge level and address specific concerns effectively.
Question 4 of 5
A nurse is making follow-up phone calls to clients being treated for cancer. Place the options below in the order of priority that the nurse should return the calls.
Order the Items
Source Container
Correct Answer: C,A,B,D
Rationale: Urinary incontinence (
C) may indicate a serious complication like spinal cord compression, requiring immediate attention. Loss of appetite (
A) during chemotherapy can lead to malnutrition, followed by the mastectomy client's support needs (
B), and then dietary questions (
D).
Question 5 of 5
A client has advanced cirrhosis of the liver. The client's spouse asks the nurse why his abdomen is swollen, making it very difficult for him to fasten his pants. How should the nurse respond to provide the most accurate explanation of the disease process?
Correct Answer: D
Rationale: Cirrhosis causes portal hypertension and hypoalbuminemia, leading to ascites (
D). Salt intake (
A) may worsen but isn't the primary cause. Ankle edema (
B) and diuretics (
C) are secondary factors.