Questions 108

NCLEX-RN

NCLEX-RN Test Bank

Med Surg RN NCLEX Questions Questions

Question 1 of 5

A client receives fibrinolytic therapy upon admission following a myocardial infarction. He is now receiving an I.V. infusion of heparin sodium at 1,200 units/hour. The dilution is 25,000 units/500 mL. How many milliliters per hour will this client receive?

Correct Answer: 24 mL/hour

Rationale:
To calculate: (1,200 units/hour ÷ 25,000 units) × 500 mL = 24 mL/hour. This is a calculation question, not multiple-choice, so no choices or correct answer letter is provided.

Question 2 of 5

A client with uric acid stones is prescribed a low-purine diet. Which food is allowed?

Correct Answer: C

Rationale: Apples are low in purines, suitable for a uric acid stone diet.

Question 3 of 5

A client returned home from an overseas tour of duty and tells the nurse he is always tired. He has a temperature of 99.5°F (37.5°C). His skin is dark bronze, and his urine has a dark color. His hemoglobin level is 9 g/dL; his hematocrit is 49, and red blood cells are 2.75 million/µL. What should the nurse do first?

Correct Answer: B

Rationale: The client's symptoms (fatigue, bronze skin, dark urine, low hemoglobin, and RBC count) suggest hemolytic anemia, possibly due to an infectious or toxic exposure overseas. Placing the client on bed rest is the priority to reduce oxygen demand and prevent further hemolysis while diagnostic evaluation proceeds. Intake/output monitoring, isolation, and sunlight avoidance are not immediate priorities.

Question 4 of 5

The nurse is obtaining a health history from a client who has a sliding hiatal hernia associated with reflux. The nurse should ask the client about the presence of which of the following symptoms?

Correct Answer: A

Rationale: Heartburn is a hallmark symptom of a sliding hiatal hernia with reflux, caused by stomach acid refluxing into the esophagus.

Question 5 of 5

A client with neutropenia is at risk for sepsis. Which of the following is the earliest sign the nurse should monitor for?

Correct Answer: B

Rationale: Tachycardia is often the earliest sign of sepsis, reflecting the body's response to infection, and requires prompt monitoring in a neutropenic client.

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