Questions 108

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Med Surg RN NCLEX Practice Questions Questions

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Question 1 of 5

Which dietary restriction is critical in acute renal failure?

Correct Answer: A

Rationale: Low sodium prevents fluid retention and hypertension in acute renal failure.

Question 2 of 5

The client with an ileal conduit will be using a reusable appliance at home. The nurse should teach the client to clean the appliance routinely with the client to clean the appliance routinely.

Correct Answer: B

Rationale: Soap is safe and effective for cleaning reusable ileal conduit appliances, removing residue without damaging the appliance or irritating the skin.

Question 3 of 5

The nurse is developing the discharge teaching plan for a client after a lumbar laminectomy L4-5 who will be returning to work in 6 weeks. Which of the following actions should the nurse encourage the client to avoid?

Correct Answer: D

Rationale: Prolonged sitting can stress the surgical site and delay healing post-laminectomy.

Question 4 of 5

A nurse should interpret which of the following as an early sign of a tension pneumothorax in a client with chest trauma?

Correct Answer: C

Rationale: Respiratory distress is an early sign of tension pneumothorax due to increasing intrathoracic pressure. Diminished breath sounds and tracheal deviation are later signs. 'Skilled heart sounds' is likely a typo and unclear.

Question 5 of 5

Nursing assessment of a 54-year-old client in the emergency department reveals severe back pain, Grey Turner's sign, nausea, blood pressure of 90/40, heart rate 128 beats per minute and respirations 28 per minute. The nurse should first:

Correct Answer: B

Rationale: Severe back pain, Grey Turner's sign (flank bruising), and hemodynamic instability (hypotension, tachycardia, tachypnea) suggest a ruptured abdominal aortic aneurysm. Placing a large-bore I.V. first ensures access for fluids and blood transfusion to stabilize the client. Urine output, positioning, and nasogastric tube are secondary.

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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?
The nurse is documenting care of a client who is restrained in bed with bilateral wrist restraints. Following assessment of the restraints, the nurse's documentation should include which of the following? Select all that apply.

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