NCLEX-RN
Med Surg RN NCLEX Practice Questions Questions
Extract:
Question 1 of 5
The nurse is documenting care of a client who is restrained in bed with bilateral wrist restraints. Following assessment of the restraints, the nurse's documentation should include which of the following? Select all that apply.
Correct Answer: A,B,C,D
Rationale: Documentation must include nutrition/hydration, circulation/skin integrity, range of motion/positioning, and behavioral/mental status to ensure safety and compliance.
Question 2 of 5
A client with osteoarthritis asks about dietary changes to manage symptoms. Which recommendation is most appropriate?
Correct Answer: B
Rationale: Omega-3 fatty acids have anti-inflammatory properties, helping manage osteoarthritis symptoms.
Question 3 of 5
The nurse is planning care for a client with a fractured humerus in a sling. Which intervention should be included?
Correct Answer: A
Rationale: Shoulder shrugging exercises maintain mobility and prevent stiffness without stressing the fracture.
Question 4 of 5
Which of the following describes decerebrate posturing?
Correct Answer: D
Rationale: Decerebrate posturing involves rigid extension of all extremities with arched back, indicating severe brain stem dysfunction. The other options describe decorticate posturing or incorrect combinations of movements.
Question 5 of 5
A client with a hemorrhagic stroke is slightly agitated, heart rate is 118, respirations are 22, bilateral rhonchi are auscultated, SpO2 is 94%, blood pressure is 144/88, and oral secretions are noted. What order of interventions should the nurse follow when suctioning the client to prevent increased intracranial pressure (ICP) and maintain adequate cerebral perfusion?
Order the Items
Source Container
Correct Answer: B,D,A,C
Rationale: The correct order is: 1) Hyperoxygenate to prevent hypoxia (
B); 2) Provide sedation to reduce agitation and ICP spikes (
D); 3) Suction the airway to clear secretions (
A); 4) Suction the mouth to remove residual secretions (
C). This sequence minimizes ICP increases and ensures oxygenation.