Questions 108

NCLEX-RN

NCLEX-RN Test Bank

Free NCLEX RN Questions for Med Surg Questions

Extract:


Question 1 of 5

Which of the following should be readily available at the bedside of a client with a chest tube in place?

Correct Answer: C

Rationale: A bottle of sterile water is needed to restore the water seal if the chamber is compromised. Tracheostomy trays, extra chest tubes, and spirometers are not immediately necessary.

Question 2 of 5

Following a transsphenoidal hypophysectomy, the nurse should assess the client for:

Correct Answer: A

Rationale: A CSF leak is a potential complication of transsphenoidal hypophysectomy due to the surgical approach through the sphenoid sinus, requiring careful monitoring.

Question 3 of 5

A client who had an exploratory laparotomy 3 days ago has a white blood cell (WBC) differential with a shift to the left. The nurse instructs unlicensed personnel to report which clinical manifestation?

Correct Answer: C

Rationale: A left shift in the WBC differential indicates an increase in immature neutrophils, often due to infection. An elevated temperature is a key sign of infection and should be reported promptly. Swelling, redness, and purulent drainage are also concerning but may develop later.

Question 4 of 5

The nurse is planning care for a client with a femoral fracture who is in balanced suspension traction. Which of the following would the nurse be least likely to include in the plan of care?

Correct Answer: C

Rationale: Elevating the head of the bed beyond 25 degrees can disrupt traction alignment, making it least appropriate.

Question 5 of 5

The nurse is caring for a client diagnosed with an anterior myocardial infarction 2 days ago. Upon assessment, the nurse identifies a new systolic murmur at the apex. The nurse should first:

Correct Answer: A

Rationale: A new systolic murmur post-myocardial infarction may indicate complications like ventricular septal rupture or mitral regurgitation. Assessing vital signs first helps determine the client's stability and guides further actions.

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