NCLEX-RN
Med Surg RN NCLEX Questions Questions
Extract:
Question 1 of 5
Which assessment is critical for a client with a recent stroke?
Correct Answer: A
Rationale: Assessing swallowing ability is critical to prevent aspiration in stroke patients.
Question 2 of 5
A client who is taking Bufferin Arthritis Strength caplets develops prolonged bleeding from a superficial skin injury on the forearm. The nurse should tell the client to do which of the following first?
Correct Answer: C
Rationale: Bufferin (aspirin) impairs platelet function, prolonging bleeding. The first action is to apply pressure by wrapping the forearm to control bleeding. Running water or patting may not provide sufficient pressure, and ice is a secondary measure after bleeding is controlled.
Question 3 of 5
A client with a hemorrhagic stroke is slightly agitated, heart rate is 118, respirations are 22, bilateral rhonchi are auscultated, SpO2 is 94%, blood pressure is 144/88, and oral secretions are noted. What order of interventions should the nurse follow when suctioning the client to prevent increased intracranial pressure (ICP) and maintain adequate cerebral perfusion?
Order the Items
Source Container
Correct Answer: B,D,A,C
Rationale: The correct order is: 1) Hyperoxygenate to prevent hypoxia (
B); 2) Provide sedation to reduce agitation and ICP spikes (
D); 3) Suction the airway to clear secretions (
A); 4) Suction the mouth to remove residual secretions (
C). This sequence minimizes ICP increases and ensures oxygenation.
Question 4 of 5
A client has returned to the medical surgical unit after having surgery to create an ileostomy. Which goal has the highest priority at this time?
Correct Answer: C
Rationale: Maintaining fluid and electrolyte balance is the highest priority post-ileostomy due to the risk of dehydration from high-output ileostomy effluent. Constipation is not a concern, and self-care or odor control are secondary to physiological stability. CN: Physiological adaptation; CL: Synthesize
Question 5 of 5
On a visit to the clinic, a client reports the onset of early symptoms of rheumatoid arthritis. The nurse should conduct a focused assessment for:
Correct Answer: C
Rationale: Early morning stiffness is a hallmark symptom of rheumatoid arthritis, especially in the early stages, as it reflects joint inflammation that worsens after periods of inactivity.