NCLEX-RN
Medical Surgical Nursing NCLEX RN Questions Questions
Extract:
Question 1 of 5
The nurse is teaching a client with polycythemia vera about potential complications from this disease. Which manifestations should the nurse include in the client's teaching plan? Select all that apply.
Correct Answer: B,C,D,E
Rationale: Polycythemia vera increases blood viscosity and red cell mass, leading to complications like visual disturbances (due to retinal hemorrhage), headaches (from hypertension or thrombosis), orthopnea (from heart failure), and gout (from increased uric acid due to cell turnover). Hearing loss and weight loss are not typical complications.
Question 2 of 5
A 56-year-old client who recently had a right pneumonectomy for lung cancer is admitted to the oncology unit with dyspnea and fever. The nurse should:
Correct Answer: C
Rationale: Deep breathing exercises promote lung expansion and oxygenation, which are critical for a post-pneumonectomy client with dyspnea and fever, potentially indicating infection or compromised lung function.
Question 3 of 5
When giving discharge instructions to the client with vasospastic disorder (Raynaud's phenomenon), the nurse should explain that the expected outcome is a total of the symptoms by:
Correct Answer: C
Rationale: The expected outcome in Raynaud's is increased blood supply to the affected areas by reducing vasospasm, alleviating symptoms like numbness and pallor. Sympathetic nervous system influence, analgesia, and monoamine oxidase are not directly targeted.
Question 4 of 5
Which assessment is most important for a client with a traumatic brain injury?
Correct Answer: A
Rationale: The Glasgow Coma Scale is critical to assess neurological status and guide management in traumatic brain injury.
Question 5 of 5
At 8 a.m., the nurse reviews the amount of T-tube drainage for a client who underwent an open cholecystectomy yesterday. After reviewing the output record (see chart), the nurse should:
Correct Answer: C
Rationale: The T-tube should drain approximately 300 to 500 mL in the fi rst 24 hours and after 3 to 4 days the amount should decrease to less than 200 mL in 24 hours. With the sudden decrease in drainage at 8 a.m., the nurse should immediately assess the tube for obstruction of flow that can be caused by kinks in the tube or the client lying on the tube. Drainage color must also be assessed for signs of bleeding. The tube should not be irrigated or clamped without an order.