NCLEX RN Med Surg Questions
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Question 1 of 5.
A client refuses to look at or care for her colostomy. Which of the following statements by the nurse would be most appropriate?
A. It has been 4 days since your surgery and you will be discussed. You have to learn to care for your colostomy before you leave the hospital.
B. I think we will need to teach your husband to care for your colostomy if you are not going to be able to do it.
C. I understand how you are feeling. It is important for you to feel attractive and you think having a colostomy changes your attractiveness.
D. I can see that you are upset. Would you like to share your concerns with me?
Explanation: It is important for the nurse to recognize that individuals go through a grieving process when adjusting to a colostomy. The nurse should be accepting and provide the client with opportunities to share her concerns and feelings when she is ready. Lecturing the client about the need to learn how to care for the colostomy is not productive, nor is attempting to shame her into caring for the colostomy by implying her husband will have to provide the care if she does not. It is not possible for the nurse to understand what the client is feeling. CN: Psychosocial adaptation; CL: Synthesize
Question 2 of 5.
A 65-year-old client is admitted to the emergency department with a fractured hip. The client has chest pain and shortness of breath. The health care provider orders nitroglycerin tablets. Which should the nurse instruct the client to do?
A. Put the tablet under the tongue until it is dissolved.
B. Swallow the tablet with 120 mL of water.
C. Chew the tablet until it is dissolved.
D. Place the tablet between his cheek and gums.
Explanation: Sublingual nitroglycerin is administered under the tongue for rapid absorption to relieve chest pain. Other methods (swallowing, chewing, or buccal placement) are incorrect for this medication.
Question 3 of 5.
After a myocardial infarction, the hospitalized client is taught to move the legs while resting in bed. This type of exercise is recommended primarily to help:
A. Prepare the client for ambulation.
B. Promote urinary and intestinal elimination.
C. Prevent thrombophlebitis and blood clot formation.
D. Decrease the likelihood of pressure ulcer formation.
Explanation: Leg exercises prevent venous stasis, reducing the risk of thrombophlebitis and deep vein thrombosis, common complications post-MI due to immobility.
Question 4 of 5.
The client who experiences angina has been told to follow a low-cholesterol diet. Which of the following meals should the nurse tell the client would be best on her low-cholesterol diet?
A. Hamburger, salad, and milkshake.
B. Baked liver, green beans, and coffee.
C. Spaghetti with tomato sauce, salad, and coffee.
D. Fried chicken, green beans, and skim milk.
Explanation: Spaghetti with tomato sauce, salad, and coffee is low in cholesterol, unlike hamburger, liver, or fried chicken, which contain higher cholesterol or saturated fats.
Question 5 of 5.
Which of the following foods should the nurse teach a client with heart failure to limit when following a 2-g sodium diet?
A. Apples.
B. Tomato juice.
C. Whole wheat bread.
D. Beef tenderloin.
Explanation: Tomato juice is high in sodium, which should be limited on a 2-g sodium diet to prevent fluid retention in heart failure.