NCLEX-RN
Medical Surgical Nursing NCLEX RN Questions Questions
Extract:
Question 1 of 5
A 250-lb male client recovering from general anesthesia has the following assessment findings: pulse, 150 bpm; blood pressure, 90/50 mm Hg; respiratory rate, 28 breaths/minute; tympanic temperature, 99.8°F (37.7°C); and rigid muscles. The nurse determines that the client is:
Correct Answer: C
Rationale: Tachycardia, hypotension, tachypnea, and muscle rigidity suggest malignant hyperthermia, a life-threatening reaction to anesthesia. Immediate action, including emergency medications like dantrolene, is required.
Question 2 of 5
A client is admitted to the hospital after sustaining burns to the chest, abdomen, right arm, and right leg. The shaded areas in the illustration indicate the burned areas on the client’s body. Using the “rule of nines,” the nurse would determine that about what percentage of the client’s body surface has been burned?
Correct Answer: C
Rationale: According to the rule of nines, this client has sustained burns on about 45% of the body surface. The right arm is calculated as being 9%, the right leg is 18%, and the anterior trunk is 18%, for a total of 45%.
Question 3 of 5
Which of the following client statements identifies a knowledge deficit about cast care?
Correct Answer: C
Rationale: Pulling out cast padding can cause skin irritation or pressure sores, indicating a knowledge deficit.
Question 4 of 5
Which complication should the nurse monitor for in a client with a new ileal conduit?
Correct Answer: A
Rationale: Stoma prolapse is a potential complication of an ileal conduit, requiring surgical correction if severe.
Question 5 of 5
Upon assessment of third degree heart block on the monitor, the nurse should first:
Correct Answer: C
Rationale: Third-degree heart block may require pacing. Having transcutaneous pacing ready is the first step to manage symptomatic bradycardia.