NCLEX-RN
Med Surg RN NCLEX Questions Questions
Extract:
Question 1 of 5
What should the nurse do first when a client with a head injury begins to have clear drainage from his nose?
Correct Answer: C
Rationale: Clear drainage from the nose after a head injury may indicate cerebrospinal fluid (CSF) leakage, a serious condition. The priority is to collect the fluid for analysis to confirm CSF and avoid infection, making providing tissues the first action. Compressing the nares or tilting the head back could increase intracranial pressure or contaminate the fluid, and an antihistamine is inappropriate without confirming the cause.
Question 2 of 5
A 56-year-old female with lung cancer is undergoing a thoracentesis. Which of the following outcomes of the procedure are expected? Select all that apply.
Correct Answer: B,C,D
Rationale: Thoracentesis diagnoses underlying disease (
B), palliates symptoms like dyspnea (
C), and relieves acute respiratory distress (
D). It does not treat recurrent effusions or remove cancer cells.
Question 3 of 5
A client with neutropenia is at risk for sepsis. Which of the following is the earliest sign the nurse should monitor for?
Correct Answer: B
Rationale: Tachycardia is often the earliest sign of sepsis, reflecting the body's response to infection, and requires prompt monitoring in a neutropenic client.
Question 4 of 5
A nurse is caring for a client 24 hours after he has undergone an abdominal-perineal resection for a bowel tumor. The client's wife asks if she can bring him some of his favorite home-cooked Italian minestrone soup. What would be an appropriate action by the nurse?
Correct Answer: A
Rationale: Auscultating for bowel sounds assesses whether the client's bowel function has returned post-surgery, which determines if oral intake like soup is safe.
Question 5 of 5
Which of the following actions should the nurse plan to do first when caring for a client who is experiencing spiritual distress?
Correct Answer: D
Rationale: Helping the client explore their own values and beliefs is the first step in addressing spiritual distress, as it establishes a foundation for personalized spiritual support.