NCLEX-RN
NCLEX RN Med Surg Questions Questions
Extract:
Question 1 of 5
The nurse is caring for a client who has just had an upper GI endoscopy. The client's vital signs must be taken every 30 minutes for 2 hours after the procedure. The nurse assigns an unlicensed nursing personnel (UAP) to take the vital signs. One hour later, the UAP reports the client, who was previously afebrile, has developed a temperature of 101.8°F (38.8°C). What should the nurse do in response to this reported assessment data?
Correct Answer: A
Rationale: A sudden fever after an upper GI endoscopy may indicate a serious complication, such as perforation, requiring immediate nursing assessment. The other options delay appropriate intervention or do not address the potential severity of the situation.
Question 2 of 5
The client asks the nurse, 'Is it really possible to lead a normal life with an ileostomy?' Which action by the nurse would be the most effective to address this question?
Correct Answer: C
Rationale: Arranging for a person with an ostomy to visit provides a relatable, firsthand perspective, addressing the client's concerns about normalcy effectively. Clergy, postponing concerns, or notifying the surgeon are less direct or supportive. CN: Psychosocial adaptation; CL: Synthesize
Question 3 of 5
Which action is contraindicated for a client with a risk of increased ICP?
Correct Answer: C
Rationale: Coughing is contraindicated as it increases intracranial pressure.
Question 4 of 5
During an initial assessment of a client diagnosed with vasospastic disorder (Raynaud's phenomenon), the nurse notes a sudden color change to white in the fingers. The nurse should first assess:
Correct Answer: B
Rationale: A sudden color change to white in Raynaud's indicates vasospasm. Assessing the radial pulse first confirms whether blood flow is present despite the vasospasm, guiding further action. Cyanosis, SpO2, and blood pressure are secondary, as pulse assessment is more immediate and specific.
Question 5 of 5
Which of the following factors would most likely contribute to the development of a client's hiatal hernia?
Correct Answer: B
Rationale: Obesity (e.g., 5'3†and 190 lb) increases intra-abdominal pressure, a major contributor to hiatal hernia development. The other factors are less directly related.