NCLEX-RN
NCLEX RN Medical Surgical Practice Questions Questions
Question 1 of 5
The nurse has provided medication instructions to a client who has been prescribed a fentanyl transdermal patch. Which of the following statements, if made by the client, would indicate a correct understanding of the instructions? Select all that apply.
Correct Answer: A,B,E
Rationale: A: Breakthrough pain may require additional medication. B: Taping a loose patch is acceptable. E: Fentanyl patches are typically changed every 72 hours. C is incorrect because heat can increase absorption and risk toxicity. D is incorrect as patches are not removed during sleep.
Question 2 of 5
After surgery and insertion of a total joint prosthesis, a client develops severe sudden pain and an inability to move the extremity. The nurse correctly interprets these findings as indicating which of the following?
Correct Answer: C
Rationale: Sudden pain and inability to move suggest joint dislocation, a surgical emergency.
Question 3 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 4 of 5
On the day of surgery, a client with diabetes who takes insulin on a sliding scale is ordered to have nothing by mouth and all medications withheld. The client's 6 a.m. glucose level is 300 mg/dL. The nurse should:
Correct Answer: C
Rationale: A glucose level of 300 mg/dL indicates significant hyperglycemia, which poses risks during surgery. Calling the physician for specific orders ensures appropriate insulin administration while adhering to NPO and surgical protocols.
Question 5 of 5
Which safety measures would be most important to implement when caring for a client who is receiving 2 units of packed red blood cells (PRBCs)? Select all that apply.
Correct Answer: A,B,C,E
Rationale: Key safety measures for PRBC transfusion include verifying ABO and Rh compatibility to prevent reactions, infusing within 4 hours to reduce infection risk, stopping the transfusion if a reaction occurs while keeping the line open, and inspecting the blood bag for abnormalities. Taking vital signs every 15 minutes is excessive (typically every 15 minutes for the first 15 minutes, then hourly). A 22-gauge catheter is too small; a larger gauge (18–20) is needed for optimal flow.