NCLEX-RN
NCLEX RN Medical Surgical Questions Questions
Extract:
Question 1 of 5
The nurse is planning care with a client with acute leukemia who has mucositis. The nurse should advise the client that after every meal and every four hours while awake the client should use:
Correct Answer: C
Rationale: Mucositis in leukemia clients requires gentle oral care to prevent infection and promote healing. Saline or baking soda solution is soothing and non-irritating. Lemon-glycerin swabs can dry the mucosa, commercial mouthwash may irritate, and brushing may cause trauma.
Question 2 of 5
The nurse is assessing a client with increasing intracranial pressure (ICP). The nurse should notify the health care provider about which of the following changes in the client's condition?
Correct Answer: A,B,C,D
Rationale: All listed changes are critical signs of increasing ICP. Widening pulse pressure (Cushing's triad), bradycardia, dilated fixed pupils, and decreased LOC indicate neurological deterioration requiring immediate notification of the health care provider for intervention.
Question 3 of 5
A client post-cystectomy is at risk for:
Correct Answer: A
Rationale: Cystectomy may impair vitamin B12 absorption due to ileum resection.
Question 4 of 5
A 42-year-old female highway construction worker is concerned about her cancer risks. She reveals that she has been married for 18 years, has two children, smokes one pack of cigarettes per day, and drinks one to two beers with her husband after work almost every day. She is 30 lb overweight, eats fast food often, and rarely eats fresh fruits and vegetables. Her mother was diagnosed with breast cancer 2 years ago. Her father and an aunt both died of lung cancer. She had a basal cell carcinoma removed from her cheek 3 years earlier. What combination of behavioral changes should the nurse instruct this client to make first?
Correct Answer: D
Rationale: Stopping smoking, using sun protection, and losing weight address the most critical modifiable risk factors for this client, given her smoking history, prior skin cancer, and obesity, which are linked to multiple cancers.
Question 5 of 5
When assessing the lower extremities of a client with peripheral vascular disease (PVD), the nurse notes bilateral ankle edema. The edema is related to:
Correct Answer: C
Rationale: Bilateral ankle edema in PVD is often due to increased venous pressure from venous insufficiency or right-sided heart failure, which impairs venous return and causes fluid to pool in the lower extremities. Decreased blood volume or increased muscular activity does not cause edema, and arterial pressure is not directly related.