NCLEX-RN
NCLEX RN Medical Surgical Questions Questions
Extract:
Question 1 of 5
The nurse is planning care for a client being admitted with bleeding esophageal varices. Vital signs are: Pulse 100; respiratory rate 22; and blood pressure 100/58. The nurse should prepare the client for which of the following? Select all that apply.
Correct Answer: A,B,C,D
Rationale: Octreotide (
A) reduces portal pressure, endoscopy (
B) diagnoses/treats bleeding, blood products (
C) address hypovolemia, and Minnesota tube (
D) controls bleeding. TIPS (E) is a later intervention, not immediate.
Question 2 of 5
A client is scheduled for an elective splenectomy. Immediately before the client goes to surgery, the nurse should determine that the client has:
Correct Answer: B
Rationale: Verifying that the client has signed the consent form is the priority before surgery to ensure informed consent and legal compliance. Voiding, recording vital signs, and checking the name band are also important but secondary to consent verification.
Question 3 of 5
A daughter is concerned that her mother is in denial when discussing her diagnosis of breast cancer because she sometimes says that breast cancer isn't that serious and changes the subject. The nurse informs the daughter that denial can be a healthy defense mechanism if it is used:
Correct Answer: D
Rationale: Denial can be healthy if it allows the client to maintain normal roles (e.g., as a mother) while gradually processing the diagnosis, as long as it doesn't interfere with treatment.
Question 4 of 5
The nurse is caring for a client whose condition has been deteriorating. The client becomes unresponsive, the blood pressure is 80/40, and SpO2 is 90% on 50% face mask. The nurse should:
Correct Answer: B
Rationale: Unresponsiveness, hypotension, and low SpO2 indicate a critical condition. Calling the rapid response team ensures immediate multidisciplinary intervention.
Question 5 of 5
A client with advanced Hodgkin's disease is admitted to hospice because death is imminent. The goal to address for the client is:
Correct Answer: A
Rationale: In hospice care for advanced Hodgkin's disease, the primary goal is to address fear of pain, ensuring comfort as death approaches. Fear of therapy, isolation, and social inadequacy are less relevant at this stage.