NCLEX-RN
NCLEX RN Medical Surgical Questions and Answers Questions
Extract:
Question 1 of 5
Which of the following nursing interventions would be most helpful in making the respiratory effort of a client with metastatic lung cancer more efficient?
Correct Answer: C
Rationale: Pursed-lip breathing helps prolong exhalation, reducing air trapping and improving respiratory efficiency in clients with metastatic lung cancer.
Question 2 of 5
Three weeks after the client has had an ileostomy, the nurse is following up with instruction about using a skin barrier around the stoma at all times. The client has been applying the skin barrier correctly when:
Correct Answer: C
Rationale: Correct application of a skin barrier is indicated by no skin irritation around the stoma, as the barrier protects the peristomal skin. Odor, hydration, and pouch change frequency are not direct indicators of proper barrier use. CN: Physiological adaptation; CL: Evaluate
Question 3 of 5
The nurse is taking care of a client who had a laryngectomy yesterday. To assure client safety, the nurse should give 'hand-off reports' at which of the following times? Select all that apply.
Correct Answer: A,B,C
Rationale: Hand-off reports are critical at change of shift, change of nurses, and when the nurse goes to lunch to ensure continuity of care and client safety.
Question 4 of 5
The nurse is preparing a client for a paracentesis. The nurse should:
Correct Answer: A
Rationale: Voiding before paracentesis (
A) prevents bladder injury. Side-lying (
B) is incorrect; upright is preferred. IV sedatives (
C) are not routine, and NPO (
D) is unnecessary.
Question 5 of 5
Glulisine (Apidra) insulin is ordered to be administered to a client before each meal. To assist the day-shift nurse who is receiving the report, the night-shift nurse gives the morning dose of glulisine. When the day-shift nurse goes to the room of the client who requires glulisine, the nurse finds that the client is not in the room. The client's roommate tells the nurse that the client 'went for a test.' What should the nurse do next?
Correct Answer: A
Rationale: Glulisine is rapid-acting insulin, and the client must eat within 15 minutes to prevent hypoglycemia. The nurse should locate the client and provide juice to counteract potential hypoglycemia.