NCLEX-RN
NCLEX RN Medical Surgical Questions and Answers Questions
Extract:
Question 1 of 5
Which of the following is not a typical clinical manifestation of multiple sclerosis (MS)?
Correct Answer: B
Rationale: Sudden bursts of energy are not typical in MS, which often causes fatigue. Double vision, weakness, and tremors are common due to demyelination affecting vision, motor, and coordination.
Question 2 of 5
The nurse is assessing a hospitalized older client for the presence of pressure ulcers. The nurse notes that the client has a 1" × 1" area on his sacrum in which there is skin breakdown as far as the dermis. What should the nurse note on the chart?
Correct Answer: B
Rationale: A Stage II pressure ulcer involves partial-thickness skin loss extending to the dermis, matching the description of the sacral breakdown.
Question 3 of 5
A client on peritoneal dialysis reports cloudy effluent. The nurse should:
Correct Answer: B
Rationale: Cloudy effluent suggests peritonitis, requiring immediate medical attention.
Question 4 of 5
The nurse teaches the client with an ileal conduit measures to prevent a urinary loss. Which of the following measures would be most effective?
Correct Answer: B
Rationale: Maintaining high fluid intake (2,000-3,000 mL) prevents urinary stasis and infection, the most effective measure for reducing urinary loss risk.
Question 5 of 5
Which nursing intervention has been found to be the most effective means of preventing plantar flexion in a client who has had a stroke with residual paralysis?
Correct Answer: A
Rationale: A firm footboard maintains the foot in a neutral position, preventing plantar flexion contractures. Repositioning, shoes, or massage are less effective for this specific purpose.