NCLEX-RN
Medical Surgical Nursing NCLEX RN Questions Questions
Extract:
Question 1 of 5
Which of the following is the most important goal of nursing care for a client who is in shock?
Correct Answer: C
Rationale: Shock is characterized by inadequate tissue perfusion due to insufficient blood flow. The primary nursing goal is to restore perfusion to vital organs through fluid resuscitation, medications, or other interventions. Fluid overload, increased cardiac output, and vasoconstriction are not primary concerns.
Question 2 of 5
It is the night before a client is to have a computed tomography (CT) scan of the head without contrast. The nurse should tell the client?
Correct Answer: D
Rationale: Holding the head still during a CT scan is essential to obtain clear images. Shampooing, fasting, or shaving hair for electrodes are not required for a non-contrast head CT.
Question 3 of 5
A client who had a cholecystectomy has a biliary drainage tube in place. Which of the following colors of the drainage is expected?
Correct Answer: D
Rationale: Biliary drainage after cholecystectomy is typically green due to bile, which is produced by the liver and stored in the gallbladder.
Question 4 of 5
A nurse is assessing a client who has been admitted with a diagnosis of an obstruction in the small intestine. The nurse should assess the client for? Select all that apply.
Correct Answer: A,B,D,E
Rationale: Small intestinal obstruction can cause projectile vomiting (
A), abdominal distention (
B), rapid dehydration (
D) due to fluid loss, and increased bowel sounds (E) proximal to the obstruction. Copious diarrhea (
C) is less likely as stool passage is blocked. CN: Physiological adaptation; CL: Analyze
Question 5 of 5
A 38-year-old female client with a history of breast-conserving surgery, axillary node dissection, and radiation therapy reports that her arm is red, warm to touch, and slightly swollen. Which of the following actions should the nurse suggest?
Correct Answer: C
Rationale: Redness, warmth, and swelling suggest cellulitis, a serious infection in a client with a history of axillary node dissection, requiring immediate medical evaluation.