NCLEX-RN
NCLEX RN Medical Surgical Questions and Answers Questions
Extract:
Question 1 of 5
The nurse is assessing an older adult's skin. The assessment will involve inspecting the skin for color, pigmentation, and vascularity. The critical component in the nurse's assessment is noting the:
Correct Answer: B
Rationale: Noting changes from normal findings is critical, as it helps identify abnormalities like lesions or discoloration that may indicate pathology, beyond expected age-related changes.
Question 2 of 5
A female client who has a urinary diversion tells the nurse, 'This urinary pouch is embarrassing. Everyone will know that I'm not normal. I don't see how I can go out in public anymore.' The most appropriate nursing diagnosis for this client is:
Correct Answer: D
Rationale: The client's statement reflects distress about the urinary diversion's impact on her appearance and social life, indicating a disturbed body image.
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
A client with microcytic anemia is having trouble selecting food from the hospital menu. Which food is best for the nurse to suggest for satisfying the client's nutritional needs?
Correct Answer: A
Rationale: Microcytic anemia is often due to iron deficiency. Egg yolks are a good source of iron, particularly heme iron, which is highly bioavailable. Brown rice and vegetables contain non-heme iron but in lower amounts, and tea inhibits iron absorption due to tannins. Egg yolks are the best choice.
Question 5 of 5
The best indicator that the client has learned how to give an insulin self-injection correctly is when the client can:
Correct Answer: A
Rationale: The ability to perform the insulin injection safely and correctly demonstrates mastery of the skill, which is the best indicator of learning.