NCLEX-RN
Medical Surgical NCLEX RN Questions
Extract:
Question 1 of 5
The nurse is planning care for an 80-year-old client with a pressure ulcer (see figure). The nurse should do which of the following? Select all that apply.
Correct Answer: C,D,E
Rationale: Protective dressings, frequent repositioning, and pressure-relieving mattresses promote healing and prevent worsening of pressure ulcers. High head elevation increases shear, and daily cultures are unnecessary unless infection is suspected.
Question 2 of 5
Which of the following findings would suggest pneumothorax in a trauma victim?
Correct Answer: D
Rationale: Absent breath sounds on the affected side suggest pneumothorax due to air in the pleural space. Crackles, wheezing, and dullness are more indicative of other conditions.
Question 3 of 5
The nurse is instructing a client with COPD how to do pursed-lip breathing. In which order should the nurse explain the steps to the client?
Order the Items
Source Container
Correct Answer: B,A,C,D
Rationale: The correct order for pursed-lip breathing is: relax muscles (
B), inhale through nose for 2 counts (
A), pucker lips (
C), exhale through pursed lips for 4 counts (
D). This prolongs exhalation, reducing air trapping.
Question 4 of 5
The client is diagnosed in the emergency department with a detached retina in the right eye. The nurse should do which of the following first?
Correct Answer: D
Rationale: Limiting mobility is the priority to prevent further detachment of the retina by reducing eye movement and strain until surgical intervention can be performed.
Question 5 of 5
A client has undergone a cystectomy and an ileal conduit diversion. What should the nurse incorporate into the discharge instructions? Select all that apply.
Correct Answer: A,D
Rationale: An adequate fluid intake aids in the prevention of urinary calculi and infection. Odor-producing foods should be avoided as they can affect the client's lifestyle and relationships. Minimizing activities can lead to urinary stasis, promoting infection. Alkaline urine may increase infection risk, and snug clothing is not recommended as it may irritate the stoma.