NCLEX RN Medical Surgical Practice Questions

NCLEX RN Medical Surgical Practice Questions Related

Review NCLEX RN Medical Surgical Practice Questions related questions and content

The nurse in the emergency department (ED) is caring for a 62-year-old male client.
Item 6 of 6
Triage Note
1700:
• The client was brought to the ED after collapsing on a tennis court.
• Vital signs: BP 94/57, T 105° F (40.5° C), P 115, RR 26, Pulse oximetry 95% on room air. • The client is lethargic and confused. Skin is pale, and there is some perspiration on the forehead. Thready peripheral pulses, clear lung fields bilaterally, tachypnea, shallow respirations.

Which two (2) findings in the nurses' note would require immediate follow-up and reported to the physician?

  • A. Rectal temperature
  • B. Generalized shivering
  • C. Urine output
  • D. Assessment of the peripheral pulses
  • E. Client reports of thirst
Correct Answer: B,C

Rationale: Generalized shivering may indicate worsening hypothermia or a cooling blanket complication, and low urine output suggests renal hypoperfusion or acute kidney injury, both requiring immediate physician notification. Temperature (A), pulses (D), and thirst (E) are expected or less urgent.

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As a first step in teaching a woman with a spinal cord injury and quadriplegia about her sexual health, the nurse assesses her understanding of her current sexual functioning. Which of the following statements by the client indicates she understands her current ability?

  • A. I will be able to have sexual intercourse until the urinary catheter is removed.'
  • B. I can participate in sexual activity but might not experience orgasm.'
  • C. I can't have sexual intercourse because it causes hypertension, but other sexual activity is okay.'
  • D. I should be able to participate in sexual activity, but I will be infertile.'
Correct Answer: B

Rationale: Quadriplegia may impair sensation and orgasm but does not preclude sexual activity, which the client correctly understands.

A client's arterial blood gas values are as follows: pH, 7.31; PaO2, 80 mm Hg; PaCO2, 65 mm Hg; HCO3ˆ’, 36 mEq/L. The nurse should assess the client for?

  • A. Cyanosis.
  • B. Flushed skin.
  • C. Irritability.
  • D. Anxiety.
Correct Answer: C

Rationale: The ABG shows uncompensated respiratory acidosis (low pH, high PaCO2) with adequate oxygenation (PaO2 80). Irritability is a symptom of CO2 retention. Cyanosis requires lower PaO2. Flushed skin and anxiety are less specific.

If a client is receiving rescue breaths and the chest wall fails to rise during cardiopulmonary resuscitation, the rescuer should first:

  • A. Try using an ambu bag.
  • B. Decrease the rate of compressions.
  • C. Intubate the client.
  • D. Reposition the airway.
Correct Answer: D

Rationale: Failure of the chest to rise during rescue breaths suggests airway obstruction or improper positioning. Repositioning the airway (e.g., head-tilt-chin-lift) is the first step.

The nurse is teaching the client about home blood glucose monitoring. Which of the following blood glucose measurements indicates hypoglycemia?

  • A. 59 mg/dL.
  • B. 75 mg/dL.
  • C. 108 mg/dL.
  • D. 119 mg/dL.
Correct Answer: A

Rationale: A blood glucose level of 59 mg/dL is below the normal range (<70 mg/dL) and indicates hypoglycemia, requiring immediate intervention.

A client has a history of heart failure and has been taking several medications, including furosemide (Lasix), digoxin (Lanoxin) and potassium chloride. The client has nausea, blurred vision, headache, and weakness. The nurse notes that the client is confused. The telemetry strip shows first-degree atrioventricular block. The nurse should assess the client for signs of which condition?

  • A. Hyperkalemia.
  • B. Digoxin toxicity.
  • C. Fluid deficit.
  • D. Pulmonary edema.
Correct Answer: B

Rationale: Nausea, blurred vision, confusion, and AV block are classic signs of digoxin toxicity, especially in a client taking digoxin, requiring immediate assessment.

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