NCLEX-RN
NCLEX RN Medical Surgical Questions and Answers Questions
Extract:
Question 1 of 5
The nurse is taking care of a client who had a laryngectomy yesterday. To assure client safety, the nurse should give 'hand-off reports' at which of the following times? Select all that apply.
Correct Answer: A,B,C
Rationale: Hand-off reports are critical at change of shift, change of nurses, and when the nurse goes to lunch to ensure continuity of care and client safety.
Question 2 of 5
The nurse is assessing a client with chronic pain. Which of the following is an expected response?
Correct Answer: B
Rationale: Chronic pain often results in normal vital signs (due to adaptation), physical inactivity (to avoid pain), and unusual physical sensitivity, as patients may guard or protect painful areas.
Question 3 of 5
The most effective measure the nurse can use to prevent wound infection when changing a client's dressing after coronary artery bypass surgery is to:
Correct Answer: A
Rationale: Hand-washing is the most effective measure to prevent wound infection, as it reduces the risk of introducing pathogens during dressing changes.
Question 4 of 5
A client with Crohn's disease has concentrated urine, decreased urinary output, dry skin with decreased: decreased turgor, hypotension, and weak, thready pulses. The nurse should do which of the following first?
Correct Answer: B
Rationale: The client's symptoms indicate dehydration, requiring immediate parenteral rehydration therapy as ordered to restore fluid balance. Oral fluids, repositioning, or monitoring are less urgent or inappropriate as the first action. CN: Physiological adaptation; CL: Synthesize
Question 5 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.