NCLEX-RN
NCLEX RN Questions Medical Surgical Nursing Questions
Extract:
Question 1 of 5
The nurse is planning care for a client who had surgery for abdominal aortic aneurysm repair 2 days ago. The pain medication and the use of relaxation and imagery techniques are not relieving the client's pain and the client refuses to get out of bed to ambulate as ordered. The nurse contacts the physician, explains the situation, and provides information about drug dose, frequency of administration, the client's vital signs, and the client's score on the pain scale. The physician tells the nurse that the current order for pain medication is sufficient and the client will be fine in a few days. The nurse should next:
Correct Answer: A
Rationale: The nurse should advocate for the client by reiterating to the physician that the current pain management is ineffective, preventing ambulation, which is critical for recovery post-AAA repair. This aligns with ethical and professional standards. Asking another provider, waiting, or reporting to the team leader delays care.
Question 2 of 5
A 57-year-old with diabetes insipidus is hospitalized for care. Which finding should the nurse report to the physician?
Correct Answer: B
Rationale: Diabetes insipidus causes excessive dilute urine output. A urine specific gravity of 1.001 (very dilute) indicates worsening of the condition and should be reported. The other findings are within normal or expected ranges.
Question 3 of 5
A client with a diagnosis of cancer is frequently disruptive and challenges the nurse. This behavior is probably caused by:
Correct Answer: A
Rationale: Disruptive behavior in a cancer client is often driven by uncertainty and fear of recurrence, reflecting ongoing emotional distress.
Question 4 of 5
The client with a laryngectomy is being discharged. The nurse should determine that the client understands to do which of the following self-care measures? Select all that apply.
Correct Answer: A,B,C
Rationale: Self-care measures include home humidification to keep the airway moist, using a stoma shield during bathing to prevent water entry, and consuming 2-3 L/day of fluids to maintain hydration. Spicy foods and low-fiber diets are not typically restricted.
Question 5 of 5
When a client with thrombocytopenia has a severe headache, the nurse interprets that this may indicate which of the following?
Correct Answer: B
Rationale: Thrombocytopenia increases the risk of bleeding, and a severe headache may indicate cerebral bleeding, a life-threatening complication. The nurse should prioritize this possibility over stress, migraine, or sinus issues, which are less likely in this context.