NCLEX-RN
NCLEX RN Questions Medical Surgical Nursing Questions
Extract:
Question 1 of 5
A 57-year-old with diabetes insipidus is hospitalized for care. Which finding should the nurse report to the physician?
Correct Answer: B
Rationale: Diabetes insipidus causes excessive dilute urine output. A urine specific gravity of 1.001 (very dilute) indicates worsening of the condition and should be reported. The other findings are within normal or expected ranges.
Question 2 of 5
A client developed shock after a severe myocardial infarction and has now developed acute renal failure. The nurse should base the response on the knowledge that there was:
Correct Answer: A
Rationale: Decreased renal blood flow from shock post-myocardial infarction reduces kidney perfusion, leading to acute renal failure.
Question 3 of 5
A client has chest pain rated at 8 on a 10 point visual analog scale. The 12-lead electrocardiogram reveals ST elevation in the inferior leads and Troponin levels are elevated. What is the highest priority for nursing management of this client at this time?
Correct Answer: D
Rationale: The client is experiencing an acute myocardial infarction, indicated by ST elevation and elevated troponin. Reducing pain and myocardial oxygen demand is critical to minimize further cardiac damage.
Question 4 of 5
A client arrives in the emergency department with an ischemic stroke and receives tissue plasminogen activator (t-PA) administration. The nurse should first:
Correct Answer: C
Rationale: The time of stroke onset is critical for t-PA administration, as it must be given within a specific window (typically 3-4.5 hours) to be effective and safe. Other assessments follow this priority.
Question 5 of 5
A 10-year-old client is diagnosed with infectious mononucleosis. Her white blood cell (WBC) count is 19,000/µL. She has a streptococcal throat infection and her spleen is enlarged. She has aching muscles. Which of the following instructions should the nurse include in discharge planning with the client and the essential caregiver? Select all that apply.
Correct Answer: B,C,E
Rationale: Infectious mononucleosis with an enlarged spleen requires avoiding contact sports to prevent splenic rupture, a serious complication. Gargling with warm saline soothes the throat, and increased fluids support recovery and prevent dehydration. Bed rest is not strictly necessary unless fever persists, and aspirin should be avoided in children due to the risk of Reye's syndrome.