NCLEX-RN
NCLEX RN Medical Surgical Practice Questions Questions
Extract:
Question 1 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 2 of 5
The client asks the nurse, 'Why can't the doctor tell me exactly how much of my leg they're going to take off? Don't you think I should know that?' The nurse responds, knowing that the final decision on the level of the amputation will depend primarily on:
Correct Answer: B
Rationale: The level of amputation depends primarily on the adequacy of blood supply to the tissues, as determined intraoperatively. Sufficient perfusion is necessary for healing and preventing further necrosis. Removing excess tissue, prosthesis fitting, or walking ability are secondary considerations.
Question 3 of 5
A client receiving radiation to the head and neck is experiencing stomatitis. The nurse should recommend:
Correct Answer: C
Rationale: Artificial saliva helps relieve dry mouth and discomfort from stomatitis, a common side effect of head and neck radiation, by maintaining oral moisture.
Question 4 of 5
A client is receiving vincristine (Oncovin). Client teaching by the nurse should include instructions on:
Correct Answer: D
Rationale: Vincristine commonly causes constipation due to neurotoxicity. A bowel regimen (e.g., stool softeners, laxatives) is essential to prevent and manage this side effect.
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.