NCLEX-RN
NCLEX RN Medical Surgical Practice Questions Questions
Question 1 of 5
A client with chest pain is prescribed intravenous nitroglycerin (Tridil). Which assessment is of greatest concern for the nurse initiating the nitroglycerin drip?
Correct Answer: B
Rationale: Nitroglycerin causes vasodilation, which can lower blood pressure. A blood pressure of 88/46 indicates hypotension, a significant concern as it may compromise perfusion, making it the priority assessment.
Question 2 of 5
The nurse is assessing a client who has had a myocardial infarction. The nurse notes the cardiac rhythm shown on the electrocardiogram strip below. The nurse identifies this rhythm as which of the following?
Correct Answer: D
Rationale: Sinus tachycardia is a fast but regular rhythm originating from the sinoatrial node, typically occurring in response to factors like pain, fever, anxiety, or myocardial infarction.
Question 3 of 5
A 68-year-old female client on day 2 after hip surgery has no cardiac history but reports having chest heaviness. The first nursing action should be to:
Correct Answer: A
Rationale: Assessing the characteristics of chest heaviness clarifies whether it is cardiac (e.g., angina) or non-cardiac, guiding further actions like oxygen or physician notification.
Question 4 of 5
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?
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.
Question 5 of 5
A client experiences initial indications of excitation after having an I.V. infusion of lidocaine hydrochloride started. The nurse should further assess the client when the client reports having:
Correct Answer: B
Rationale: Tinnitus is a sign of lidocaine toxicity, requiring further assessment to prevent serious complications like seizures or arrhythmias.