NCLEX-RN
NCLEX RN Medical Surgical Questions and Answers Questions
Extract:
Question 1 of 5
To provide oral hygiene for a client recovering from transsphenoidal hypophysectomy, the nurse should instruct the client to:
Correct Answer: A
Rationale: Saline mouth rinses are gentle and safe post-transsphenoidal hypophysectomy, avoiding irritation to the surgical site.
Question 2 of 5
A client with acute respiratory distress syndrome (ARDS) is on a ventilator. The client's peak inspiratory pressures and spontaneous respiratory rate are increasing, and the PO2 is not improving. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse calls the physician with the recommendation for:
Correct Answer: A
Rationale: Increasing peak pressures, respiratory rate, and poor PO2 suggest agitation or asynchrony; I.V. sedation improves ventilator synchrony. Diet and pain medication are irrelevant. Increasing ventilator rate may worsen lung injury.
Question 3 of 5
The nurse sees a client walking in the hallway who begins to have a seizure. The nurse should do which of the following in priority order?
Order the Items
Source Container
Correct Answer: C,A,B,D
Rationale: The priority order is: 1) Ease the client to the floor to prevent injury (
C); 2) Maintain a patent airway to ensure oxygenation (
A); 3) Record seizure activity for accurate reporting (
B); 4) Obtain vital signs post-seizure to assess stability (
D).
Question 4 of 5
A client is to have a transfusion of packed red blood cells from a designated donor. The client asks if any diseases can be transmitted by this donor. The nurse should inform the client that which of the following diseases can be transmitted by a designated donor? Select all that apply.
Correct Answer: B,C,E
Rationale: Blood transfusions, even from designated donors, carry a risk of transmitting certain diseases. HIV, CMV, and malaria are known to be transmissible through blood transfusions if the donor is infected, as these pathogens can persist in blood. Epstein-Barr virus is less commonly associated with transfusion transmission, and hepatitis A is primarily transmitted via the fecal-oral route, not blood. The nurse should inform the client of the risks of HIV, CMV, and malaria.
Question 5 of 5
The nurse is planning care for a client who is diagnosed with peripheral vascular disease (PVD) and has a history of heart failure. The nurse should develop a plan of care that is based on the fact that the client may have a low tolerance for exercise related to:
Correct Answer: A
Rationale: In PVD, decreased blood flow to the extremities limits oxygen delivery to muscles, reducing exercise tolerance. In heart failure, reduced cardiac output further exacerbates this limitation, as the heart cannot meet increased oxygen demands during activity. Increased blood flow or viscosity is not relevant, and the options are repeated incorrectly in the document.