Questions 108

NCLEX-RN

NCLEX-RN Test Bank

Medical Surgical Nursing NCLEX RN Questions Questions

Extract:


Question 1 of 5

Which of the following interventions should the nurse anticipate in a client who has been diagnosed with acute respiratory distress syndrome (ARDS)?

Correct Answer: C

Rationale: ARDS with severe hypoxemia typically requires mechanical ventilation to support oxygenation and ventilation. Tracheostomy is considered later. Nasal cannula is inadequate. Chest tubes are for pneumothorax, not ARDS.

Question 2 of 5

What should the nurse assess first in a client with a recent head injury?

Correct Answer: A

Rationale: Pupil response is assessed first to detect neurological changes, such as increased intracranial pressure, in a head injury.

Question 3 of 5

What diet should be implemented for a client who is in the early stages of cirrhosis?

Correct Answer: A

Rationale: A high-calorie, high-carbohydrate diet (
A) supports energy needs in early cirrhosis. High-protein (
B) may worsen encephalopathy. Low-fat, low-protein (
C) is too restrictive. Low-sodium (
D) is relevant for ascites, not early cirrhosis.

Question 4 of 5

The nurse reviews an arterial blood gas report for a client with chronic obstructive pulmonary disease (COPD). pH 7.35; PCO2 62; PO2 70; HCO3 34. The nurse should:

Correct Answer: B

Rationale: The ABG shows compensated respiratory acidosis (normal pH, high PCO2, high HCO3) with mild hypoxemia (PO2 70). Assessing vital signs evaluates stability before escalating care. A non-rebreather mask or intubation is premature. Repositioning may help but is less urgent.

Question 5 of 5

Which of the following client statements identifies a knowledge deficit about cast care?

Correct Answer: C

Rationale: Pulling out cast padding can cause skin irritation or pressure sores, indicating a knowledge deficit.

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