NCLEX-RN
NCLEX RN Medical Surgical Questions and Answers Questions
Extract:
Question 1 of 5
Which of the following nursing interventions would most likely promote self-care behaviors in the client with a hiatal hernia?
Correct Answer: C
Rationale: Encouraging the client to identify past instances of responsibility promotes self-efficacy and motivates self-care behaviors, which is most effective for long-term management.
Question 2 of 5
A client with an extracapsular hip fracture returns to the nursing unit after internal fixation and pin insertion with a drainage tube at the incision site. Her husband asks, 'Why does she have this tube inserted in her hip?' Which of the following responses would be best?
Correct Answer: C
Rationale: The drainage tube prevents fluid accumulation, reducing infection risk and promoting healing.
Question 3 of 5
A nurse is assessing a 42-year-old client who has been receiving chemotherapy. The client has a platelet count of 22,000 cells/mm³ and has petechiae on the lower extremities. The nurse should advise the client to:
Correct Answer: D
Rationale: A platelet count of 22,000/mm³ with petechiae indicates severe thrombocytopenia, requiring urgent consultation with the oncologist for potential platelet transfusion or treatment adjustment.
Question 4 of 5
The nurse sees a client walking in the hallway who begins to have a seizure. The nurse should do which of the following in priority order?
Order the Items
Source Container
Correct Answer: C,A,B,D
Rationale: The priority order is: 1) Ease the client to the floor to prevent injury (
C); 2) Maintain a patent airway to ensure oxygenation (
A); 3) Record seizure activity for accurate reporting (
B); 4) Obtain vital signs post-seizure to assess stability (
D).
Question 5 of 5
The nurse is planning care for a client on complete bed rest. The plan of care should include all except which of the following:
Correct Answer: D
Rationale: Maintaining the client in the supine position is not recommended, as it promotes stasis and pressure ulcers. Turning every 2 hours, range-of-motion exercises, and TED hose prevent complications like thrombophlebitis and skin breakdown during bed rest.