NCLEX-RN
Medical Surgical Nursing NCLEX RN Questions Questions
Extract:
Question 1 of 5
What should the nurse teach a client about how to avoid the dumping syndrome? Select all that apply.
Correct Answer: C,D,E
Rationale:
To avoid dumping syndrome, clients should reduce fluids with meals, ensure adequate protein and fat, and eat in a relaxing environment. Three meals a day and high-carbohydrate foods can exacerbate symptoms.
Question 2 of 5
Which of the following interventions is most appropriate for a client who has stomatitis?
Correct Answer: D
Rationale: Stomatitis involves inflammation of the oral mucosa, often causing pain and sensitivity. A soft, bland diet is most appropriate as it minimizes irritation and discomfort during eating. Hot tea, antiseptic mouthwash, and electric toothbrushes can exacerbate irritation or pain in the inflamed oral tissues.
Question 3 of 5
The nurse is assessing a client with heart failure who is receiving home health care monitoring using electronic devices including scales, blood pressure monitoring, and structured questions to which the client responds daily on a touch-screen monitor. The nurse reviews data obtained within the last 3 days. The nurse calls the client to follow up. The nurse should ask the client which of the following first:
Correct Answer: B
Rationale: A 5-lb weight gain in 3 days and rising blood pressure suggest fluid retention. Asking about shortness of breath first assesses for pulmonary edema, a serious complication.
Question 4 of 5
At 8 a.m., the nurse reviews the amount of T-tube drainage for a client who underwent an open cholecystectomy yesterday. After reviewing the output record (see chart), the nurse should:
Correct Answer: C
Rationale: The T-tube should drain approximately 300 to 500 mL in the fi rst 24 hours and after 3 to 4 days the amount should decrease to less than 200 mL in 24 hours. With the sudden decrease in drainage at 8 a.m., the nurse should immediately assess the tube for obstruction of flow that can be caused by kinks in the tube or the client lying on the tube. Drainage color must also be assessed for signs of bleeding. The tube should not be irrigated or clamped without an order.
Question 5 of 5
The nurse evaluates the effectiveness of the client's postoperative plan of care. Which of the following would be an expected outcome for a client with an ileal conduit?
Correct Answer: D
Rationale: Frequent pouch emptying is an expected outcome, preventing complications like leakage or infection. Aspirin is unsafe, and stoma catheterization is not typical.