NCLEX-RN
Free NCLEX RN Questions for Med Surg Questions
Question 1 of 5
The nurse is caring for a client diagnosed with an anterior myocardial infarction 2 days ago. Upon assessment, the nurse identifies a new systolic murmur at the apex. The nurse should first:
Correct Answer: A
Rationale: A new systolic murmur post-myocardial infarction may indicate complications like ventricular septal rupture or mitral regurgitation. Assessing vital signs first helps determine the client's stability and guides further actions.
Question 2 of 5
While caring for a client who has sustained a myocardial infarction (MI), the nurse notes eight premature ventricular contractions (PVCs) in 1 minute on the cardiac monitor. The client is receiving an I.V. infusion of 5% dextrose in water (D5W) and oxygen at 2 L/minute. The nurse's first course of action should be:
Correct Answer: B
Rationale: Frequent PVCs (eight per minute) may indicate irritability of the myocardium, risking serious arrhythmias. Notifying the physician promptly ensures timely intervention, such as antiarrhythmic therapy.
Question 3 of 5
The nurse receives emergency laboratory results for a client with chest pain and immediately informs the physician. An increased myoglobin level suggests which of the following?
Correct Answer: D
Rationale: Elevated myoglobin indicates myocardial damage, as it is released from injured cardiac muscle, supporting a diagnosis of MI.
Question 4 of 5
A nurse is assessing a client with heart failure. The nurse should assess the client based on which compensatory mechanisms that are activated in the presence of heart failure? Select all that apply.
Correct Answer: A,B,C,D,E
Rationale: Heart failure activates the sympathetic nervous system (
A), renin-angiotensin-aldosterone system (
B), myocardial hypertrophy (
C), natriuretic peptide release (
D), and ventricular dilation (E) to compensate for reduced cardiac output.
Question 5 of 5
A pulmonary artery catheter is inserted in a client with severe mitral stenosis and regurgitation. The nurse administers furosemide (Lasix) to treat pulmonary congestion and begins a Nitroprusside (Nipride) drip for afterload reduction per physician orders. The nurse notices a sudden drop in the pulmonary artery diastolic pressure and pulmonary artery wedge pressure. Which of the following has the highest priority?
Correct Answer: B
Rationale: A sudden drop in pulmonary pressures may indicate hypotension from nitroprusside. Assessing blood pressure is the priority to ensure adequate perfusion.