NCLEX-RN
Medical Surgical Nursing NCLEX RN Questions Questions
Extract:
Question 1 of 5
Which assessment is most important for a client with a traumatic brain injury?
Correct Answer: A
Rationale: The Glasgow Coma Scale is critical to assess neurological status and guide management in traumatic brain injury.
Question 2 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 3 of 5
Which of the following assessments should be a priority immediately after nasal surgery?
Correct Answer: C
Rationale: Respiratory status is the priority post-nasal surgery due to the risk of airway obstruction from packing or swelling. Pain, ecchymosis, and fluid balance are important but secondary to airway patency.
Question 4 of 5
A client with peripheral vascular disease has chronic, severe pretibial and ankle edema bilaterally. Because the client is on complete bed rest and circulation is compromised, one goal is to maintain tissue integrity. Which of the following interventions will help achieve this outcome?
Correct Answer: C
Rationale: Turning the client every 1 to 2 hours prevents pressure ulcers by relieving pressure on dependent areas, promoting circulation, and maintaining skin integrity in a client with PVD and edema on bed rest. Pain medication, fluids, and hygiene are important but do not directly address tissue integrity.
Question 5 of 5
If a client displays risk factors for coronary artery disease, such as smoking cigarettes, eating a diet high in saturated fat, or leading a sedentary lifestyle, techniques of behavior modification may be used to help the client change the behavior. The nurse can best reinforce new adaptive behaviors by:
Correct Answer: C
Rationale: Positive reinforcement, such as rewarding adaptive behaviors, encourages the client to continue healthy habits. Fear or delayed praise is less effective for behavior modification.