Medical Surgical Nursing NCLEX RN Questions

Medical Surgical Nursing NCLEX RN Questions Related

Review Medical Surgical Nursing NCLEX RN Questions related questions and content

The following scenario applies to the next 1 items
The nurse has received prescriptions for a newborn infant in the postpartum unit.
Item 1 of 1
Orders
1958:
• phytonadione 1 mg intramuscular (IM) x 1 dose
• erythromycin ophthalmic ointment 0.5% apply from unit dose (1 cm) to both eyes
The nurse administers the prescribed medications.

The nurse should administer the phytonadione using ............ The nurse will inject the medication.............................It would be appropriate for the nurse to ...................... The nurse understands that the purpose of administering newborn erythromycin ophthalmic ointment is ............................. The nurse should apply this ointment to the ......................... Once the ointment is administered, the nurse should ..........................

  • A. ¾-in, 25-gauge needle.
  • B. into the middle third of the anterolateral aspect of the thigh.
  • C. aspirate before injecting the medication.
  • D. massage the area to promote medication absorption.
  • E. prevent ophthalmia neonatorum caused by Neisseria gonorrhoeae.
  • F. lower conjunctival sac.
  • G. wipe the ointment from the outer eye after one minute.
Correct Answer: A,B,D,E,F

Rationale: Phytonadione is administered with a 25-gauge, ¾-in needle in the vastus lateralis; erythromycin prevents ophthalmia neonatorum and is applied to the lower conjunctival sac without wiping.

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When administering I.V. midazolam hydrochloride (Versed) the nurse should?

  • A. Assess the blood pressure.
  • B. Monitor the pulse oximeter.
  • C. Encourage slow, deep breaths.
  • D. Explain relaxation techniques.
Correct Answer: B

Rationale: Midazolam can cause respiratory depression, so monitoring the pulse oximeter is essential to ensure adequate oxygenation during administration.

The nurse is caring for a client in skeletal traction for a femoral fracture. Which assessment should be prioritized?

  • A. Skin integrity at pin sites.
  • B. Room temperature control.
  • C. Frequency of bowel movements.
  • D. Client's emotional status.
Correct Answer: A

Rationale: Pin site infections are a common complication in skeletal traction, requiring prioritized assessment.

Which of the following is the most important goal of nursing care for a client who is in shock?

  • A. Manage fluid overload.
  • B. Manage increased cardiac output.
  • C. Manage inadequate tissue perfusion.
  • D. Manage vasoconstriction of vascular beds.
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.

A client is to have a cystoscopy to rule out cancer of the bladder. Which of the following indicate that the client has developed a complication after the cystoscopy?

  • A. Dizziness.
  • B. 2. skills.
  • C. Pink-tinged urine.
  • D. Bladder spasms.
Correct Answer: D

Rationale: Bladder spasms post-cystoscopy indicate a complication, often due to irritation or trauma to the bladder lining, requiring medical attention. Pink-tinged urine is expected, and dizziness may relate to other causes.

Which of the following interventions should the nurse include in the client's plan of care to prevent complications associated with TPN administered through a central line?

  • A. Use a clean technique for all dressing changes.
  • B. Tape all connections of the system.
  • C. Encourage bed rest.
  • D. Cover the insertion site with a moisture-proof dressing.
Correct Answer: B,D

Rationale: To prevent complications with TPN via a central line, taping all connections (B) prevents dislodgement, and a moisture-proof dressing (D) reduces infection risk. Clean technique (A) is insufficient; sterile technique is required. Bed rest (C) is not necessary and may increase complications like thrombosis. CN: Pharmacological and parenteral therapies; CL: Create

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