Medical Surgical Nursing NCLEX RN Questions

Medical Surgical Nursing NCLEX RN Questions Related

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The nurse in the infusion center is caring for a 27-year-old male.
Item 1 of 1
• Nurses' Notes
1401: Orders received for PRBC transfusion. 20-gauge peripheral vascular access device (VAD) started right antecubital space. Blood return was observed, and was flushed with 10 mL of sodium chloride (normal saline) without resistance. The client denied any discomfort at the VAD. Sterile dressing was applied to the VAD. The client was provided verbal education regarding the potential blood transfusion reactions. The client verbalized understanding.
1430: PRBC unit retrieved from blood bank. Vital signs were obtained prior to starting blood transfusion: 99.0° F (37.2° C) P 78, RR 18, BP 130/86, pulse oximetry reading 97% on room air.
1439: Verified and checked client ID and blood product with another RN. Initiated PRBC transfusion via y-type tubing. Will remain with the client for 15 minutes to observe for any potential transfusion-related reaction.
1454: The client denied any manifestations of a transfusion reaction. Vital signs: 99.5°F (37.5°C) P 75, RR 18, BP 132/85, pulse oximetry reading 96% on room air. Increased rate of PRBC transfusion.
1520: The client alerted RN to come to their bedside, reporting pain and discomfort at their VAD. VAD was swollen and cool to the touch.
• Orders
• Infuse 1 unit of packed red blood cells
• Medical History
• Sickle cell anemia
• Depression

The nurse reviews the clinical data and prepares to take action following the 1520 nursing note entry. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition and 2 parameters the nurse should monitor to assess the client's progress.

  • A. pause the transfusion and discontinue the vascular access device,discontinue the packed red blood cell transfusion and return it to the blood bank
    ,start a new 20-gauge vascular access device in the opposite extremity,pause the transfusion obtain an order for acetaminophen
  • B. febrile transfusion reaction,infiltration at the vascular access device
    hemolytic transfusion reaction,circulatory overload
  • C. discomfort and swelling at vascular access site,hemoglobin and hematocrit,temperature,blood pressure
Correct Answer:

Rationale: The nurse should monitor the discomfort and swelling at the VAD site. Pausing the transfusion, elevating the extremity, and applying a compress should alleviate the discomfort and swelling.
The nurse will need to monitor the client's hemoglobin and hematocrit to determine the efficacy of the PRBC transfusion. Generally, one unit of PRBCs will raise the hemoglobin by 1 g/dL.
It is inappropriate for the nurse to monitor the client's temperature as it pertains to infiltration. The client's temperature is not relevant in managing infiltration.
The blood pressure does not require monitoring because it does not show evidence of circulatory overload.

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The nurse should tell the client to do which of the following when teaching the client about taking oral glucocorticoids?

  • A. Take your medication with a full glass of water.'
  • B. Take your medication on an empty stomach.'
  • C. Take your medication at bedtime to increase absorption.'
  • D. Take your medication with meals or with an antacid.'
Correct Answer: D

Rationale: Taking glucocorticoids with meals or an antacid reduces gastrointestinal irritation, a common side effect.

The nurse is assessing a client who has had a myocardial infarction (MI). The nurse notes the cardiac rhythm shown on the electrocardiogram strip below. The nurse identifi es this rhythm as which of the following?

  • A. Atrial fi brillation
  • B. Ventricular tachycardia.
  • C. Premature ventricular contractions (PVCs).
  • D. Third-degree heart block.
Correct Answer: C

Rationale: PVCs are early depolarizations originating in the ventricles, and they present exactly as seen in your strip.

A client receiving chemotherapy for metastatic colorectal cancer has had 2 days of vomiting. Assessment findings include: irregular pulse of 120, blood pressure 88/48, respiratory rate of 14, serum potassium of 2.9 mEq/L, and arterial blood gas€”pH 7.46, PCO‚‚ 45, PO‚‚ 95, bicarbonate level 29 mEq/L. Which of the following interventions is appropriate for the nurse to administer to the client?

  • A. Oxygen at 4 L per nasal cannula.
  • B. Potassium 40 mEq PO now.
  • C. 5% Dextrose in 0.45% Normal Saline with KCl 40 mEq/L at 125 mL/hour.
  • D. NaHCO‚ƒ 75 mEq IV.
Correct Answer: C

Rationale: Hypokalemia (2.9 mEq/L) and hypotension (88/48) due to vomiting require I.V. fluid and potassium replacement (D5 0.45% NS with KCl) to correct electrolyte imbalance and dehydration. The alkalosis (pH 7.46) does not require bicarbonate, and oral potassium is unsafe with vomiting.

The nurse is teaching a client about risk factors associated with atherosclerosis and how to reduce the risk. Which of the following is a risk factor that the client is not able to modify?

  • A. Diabetes
  • B. Age
  • C. Exercise level
  • D. Dietary preferences
Correct Answer: B

Rationale: Age is a non-modifiable risk factor for atherosclerosis, as the risk increases with advancing age due to cumulative vascular changes. Diabetes, exercise level, and dietary preferences can be managed or modified to reduce risk, making age the correct answer.

A 27-year-old female is admitted for elective nasal surgery for a deviated septum. Which of the following would be an important initial clue that bleeding was occurring even if the nasal drip pad remained dry and intact?

  • A. Complaints of nausea.
  • B. Repeated swallowing.
  • C. Rapid respiratory rate.
  • D. Feelings of anxiety.
Correct Answer: B

Rationale: Repeated swallowing may indicate postnasal bleeding, as blood may flow down the throat rather than out the nose, even if the nasal drip pad remains dry.

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