Questions 108

NCLEX-RN

NCLEX-RN Test Bank

NCLEX RN Medical Surgical Practice Questions Questions

Extract:


Question 1 of 5

The nurse monitors a client with cirrhosis for the development of hepatic encephalopathy. Which of the following would be an indication that hepatic encephalopathy is developing?

Correct Answer: A

Rationale: Hepatic encephalopathy causes decreased mental status (
A) due to ammonia buildup. Elevated blood pressure (
B), decreased urine output (
C), and labored respirations (
D) are not primary indicators.

Question 2 of 5

When assessing a client who has had spinal anesthesia, which of the following would the nurse expect to find?

Correct Answer: C

Rationale: After spinal anesthesia, sensation typically returns distally (toes) first, progressing proximally (perineal area), as the anesthetic wears off in a predictable pattern.

Question 3 of 5

Which of the following is most likely to cause the client to experience postoperative nausea and vomiting?

Correct Answer: C

Rationale: Abdominal hysterectomy involves manipulation of the gastrointestinal tract, increasing the risk of postoperative nausea and vomiting due to vagal stimulation and slowed gastric motility.

Question 4 of 5

The nurse formulates a nursing diagnosis of Spiritual distress related to advanced cancer disease. An appropriate goal for the client would be to:

Correct Answer: D

Rationale: Participating in spiritual activities of the client's choice respects their individual beliefs and supports resolution of spiritual distress.

Question 5 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

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