NCLEX-RN
NCLEX RN Med Surg Questions Questions
Extract:
Question 1 of 5
The right hand of a client with multiple sclerosis trembles severely whenever she attempts a purposeful act, such as picking up her coffee cup or buttoning her dress. Which is the best legal documentation in nurses' notes of the chart for this client assessment?
Correct Answer: D
Rationale: The most detailed and accurate documentation is: "Slight shaking of right hand increases to severe tremor when client tries to button her clothes or drink from a cup," as it describes the intention tremor specifically and legally.
Question 2 of 5
A client has recently been diagnosed with type 2 diabetes mellitus and is to take tolbutamide (Orinase). When teaching the client about the drug, the nurse explains that tolbutamide is believed to lower the blood glucose level by which of the following actions?
Correct Answer: C
Rationale:
Tolbutamide, a sulfonylurea, stimulates insulin release from pancreatic beta cells, helping to lower blood glucose levels in type 2 diabetes.
Question 3 of 5
A client with an ileal conduit reports a bulging stoma. The nurse suspects:
Correct Answer: B
Rationale: A bulging stoma suggests a parastomal hernia, a complication requiring evaluation.
Question 4 of 5
What is a goal of care for a client with acute renal failure?
Correct Answer: A
Rationale: Maintaining adequate urine output indicates improving renal function.
Question 5 of 5
The nurse is assisting a client who has had a spinal fusion apply a back brace. In which order of priority should the nurse assist the client applying the brace?
Order the Items
Source Container
Correct Answer: B,A,D,C
Rationale: Verifying the order ensures correct settings, side-lying positions the client safely, log rolling prevents twisting, and standing allows proper brace fitting.