NCLEX-RN
Medical Surgical Nursing NCLEX RN Questions Questions
Extract:
Question 1 of 5
A 60-year-old male client comes into the emergency department with a complaint of crushing substernal chest pain that radiates to his shoulder and left arm. The admitting diagnosis is acute myocardial infarction (MI). Immediate admission orders include oxygen by nasal cannula at 4 L/minute, blood work, a chest radiograph, a 12-lead electrocardiogram (ECG), and 2 mg of morphine sulfate given I.V. The nurse should first:
Correct Answer: A
Rationale: Administering morphine first relieves pain, reducing myocardial oxygen demand and stabilizing the client. ECG and blood work follow to confirm diagnosis, but pain management is the priority.
Question 2 of 5
The client has returned to the surgery unit from the Post Anesthesia Care Unit (PACU). The client's respirations are rapid and shallow, the pulse is 120, and the blood pressure is 88/52. The client's level of consciousness is deteriorating. The nurse should do which of the following first?
Correct Answer: D
Rationale: Rapid, shallow respirations, tachycardia, hypotension, and deteriorating consciousness suggest shock or respiratory distress. Calling the Rapid Response Team ensures immediate intervention.
Question 3 of 5
A client with a new ileostomy is concerned about returning to work. Which advice should the nurse provide to support the client's transition?
Correct Answer: A
Rationale: Wearing loose clothing helps conceal the ileostomy pouch, boosting the client's confidence at work. Avoiding activity is unnecessary, daily pouch changes are not required unless needed, and limiting fluids risks dehydration. CN: Psychosocial adaptation; CL: Synthesize
Question 4 of 5
A client undergoing a bilateral adrenalectomy has postoperative orders for hydromorphone hydrochloride (Dilaudid) 2 mg to be given subcutaneously every 4 hours as needed for pain. The medication is administered in relatively small doses primarily because it is:
Correct Answer: C
Rationale: Hydromorphone is a potent opioid, effective in small doses, reducing the need for larger doses that increase side effect risks.
Question 5 of 5
A client post-cystectomy is at risk for:
Correct Answer: A
Rationale: Cystectomy may impair vitamin B12 absorption due to ileum resection.