Questions 108

NCLEX-RN

NCLEX-RN Test Bank

NCLEX RN Medical Surgical Questions and Answers Questions

Extract:


Question 1 of 5

The nurse is planning care for a client on complete bed rest. The plan of care should include all except which of the following:

Correct Answer: D

Rationale: Maintaining the client in the supine position is not recommended, as it promotes stasis and pressure ulcers. Turning every 2 hours, range-of-motion exercises, and TED hose prevent complications like thrombophlebitis and skin breakdown during bed rest.

Question 2 of 5

The nurse is assessing a client post-laminectomy for complications. Which finding requires immediate action?

Correct Answer: B

Rationale: Clear drainage may indicate a cerebrospinal fluid leak, a critical complication requiring urgent intervention.

Question 3 of 5

In the oliguric phase of acute renal failure, the nurse should assess the client for:

Correct Answer: A

Rationale: Pulmonary edema is a risk in the oliguric phase due to fluid overload from reduced urine output.

Question 4 of 5

A client with chronic obstructive pulmonary disease (COPD) is experiencing dyspnea and has a low PaO2 level. The nurse plans to administer oxygen as ordered. Which of the following statements is true concerning oxygen administration to a client with COPD?

Correct Answer: B

Rationale: In COPD, high oxygen concentrations may suppress the hypoxic drive to breathe, risking CO2 retention. Oxygen does not cause coughing, dependency, or contraindication with bronchodilators.

Question 5 of 5

A nurse is assessing a 42-year-old client who has been receiving chemotherapy. The client has a platelet count of 22,000 cells/mm³ and has petechiae on the lower extremities. The nurse should advise the client to:

Correct Answer: D

Rationale: A platelet count of 22,000/mm³ with petechiae indicates severe thrombocytopenia, requiring urgent consultation with the oncologist for potential platelet transfusion or treatment adjustment.

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