NCLEX-RN
Medical Surgical Nursing NCLEX RN Questions Questions
Extract:
Question 1 of 5
While assessing a thoracotomy incisional area from which a chest tube exits, the nurse feels a crackling sensation under the fingertips along the entire incision. Which of the following should be the nurse's first action?
Correct Answer: C
Rationale: The crackling sensation indicates subcutaneous emphysema. Marking the area monitors its spread, guiding further action. Lowering the bed, preparing aspiration, or turning off suction are not immediate priorities.
Question 2 of 5
Allopurinol (Zyloprim), 200 mg/day, is prescribed for the client with renal calculi to take at home. The nurse should teach the client about which the following adverse effects of this medication?
Correct Answer: B
Rationale: Maculopapular rash is a common adverse effect of allopurinol, requiring monitoring due to potential allergic reactions.
Question 3 of 5
Which of the following interventions should the nurse anticipate in a client who has been diagnosed with acute respiratory distress syndrome (ARDS)?
Correct Answer: C
Rationale: ARDS with severe hypoxemia typically requires mechanical ventilation to support oxygenation and ventilation. Tracheostomy is considered later. Nasal cannula is inadequate. Chest tubes are for pneumothorax, not ARDS.
Question 4 of 5
A client has been taking aluminum hydroxide (Amphojel) 30 mL six times per day at home to treat his peptic ulcer. He tells the nurse that he has been unable to have a bowel movement for 3 days. Based on this information, the nurse would determine that which of the following is the most likely cause of the client's constipation?
Correct Answer: C
Rationale: Aluminum hydroxide is known to cause constipation as a common adverse effect, especially with frequent dosing. The other options are less likely given the direct association with the medication.
Question 5 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.