NCLEX-RN
NCLEX RN Medical Surgical Practice Questions Questions
Extract:
Question 1 of 5
The nurse is teaching the client how to care for her ileostomy. The client asks the nurse how long she can wear her pouch before changing it. The nurse responds:
Correct Answer: B
Rationale: An ileostomy pouch is typically worn for 4 to 7 days unless it leaks or causes skin irritation, providing a standard guideline for routine changes. Activity level and diet may influence output but are not the primary determinants for pouch change frequency. CN: Physiological adaptation; CL: Synthesize
Question 2 of 5
The nurse is aware that the diagnostic tests typically ordered for acute diverticulitis do not include a barium enema. The reason for this is that a barium enema:
Correct Answer: A
Rationale: A barium enema is avoided in acute diverticulitis because it can perforate an intestinal abscess, worsening the condition. It may cause discomfort but is not primarily avoided for pain, diagnostic value, or procedure length. CN: Reduction of risk potential; CL: Apply
Question 3 of 5
The nurse is to administer Polycillin (ampicillin) 500 mg orally to a client with a ruptured appendix. The nurse checks the capsule in the client's medication box which is located inside of the client's room. The dosage of the medication is not labeled, but the nurse recognizes the color and shape of the capsule. The nurse should next:
Correct Answer: C
Rationale: Contacting the pharmacy to bring a properly labeled medication ensures safe administration, as recognizing the capsule's color and shape is insufficient for verification. Administering without confirmation or relying on another nurse risks error, and reporting to the manager delays care. CN: Safety and infection control; CL: Synthesize
Question 4 of 5
The nurse is teaching a client post-appendectomy about activity restrictions. Which instruction is most appropriate?
Correct Answer: A
Rationale: Avoiding lifting more than 10 pounds for 4–6 weeks prevents strain on the surgical site post-appendectomy. Resuming full activity too soon, avoiding walking, or doing sit-ups could impair healing. CN: Physiological adaptation; CL: Synthesize
Question 5 of 5
After a client who has had a laparoscopic cholecystectomy receives discharge instructions, which of the following client statements would indicate that the teaching has been successful? Select all that apply.
Correct Answer: C,E
Rationale: Right shoulder pain (
C) can occur due to referred pain from diaphragmatic irritation. Washing the puncture site with mild soap and water (E) is correct for hygiene. Resuming a normal diet immediately (
A) is incorrect; a low-fat diet is advised. Avoiding driving for 4 weeks (
B) is excessive; 1-2 weeks is typical. Bed rest for 2-3 days (
D) is unnecessary as early ambulation is encouraged.