NCLEX-RN
NCLEX RN Medical Surgical Practice Questions Questions
Extract:
Question 1 of 5
A client experiences initial indications of excitation after having an I.V. infusion of lidocaine hydrochloride started. The nurse should further assess the client when the client reports having:
Correct Answer: B
Rationale: Tinnitus is a sign of lidocaine toxicity, requiring further assessment to prevent serious complications like seizures or arrhythmias.
Question 2 of 5
The nurse is teaching the client how to care for her ileostomy. The client asks the nurse how long she can wear her pouch before changing it. The nurse responds:
Correct Answer: B
Rationale: An ileostomy pouch is typically worn for 4 to 7 days unless it leaks or causes skin irritation, providing a standard guideline for routine changes. Activity level and diet may influence output but are not the primary determinants for pouch change frequency. CN: Physiological adaptation; CL: Synthesize
Question 3 of 5
When teaching the client to care for an ileal conduit, the nurse instructs the client to empty the appliance frequently. Which of the following indicate that the client is following instructions?
Correct Answer: C,D
Rationale: No odor and an intact seal indicate frequent emptying, preventing urine leakage and skin irritation. Red skin or deep yellow urine suggest inadequate care or dehydration.
Question 4 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.
Question 5 of 5
A client is admitted from a nursing home with an acute onset of shortness of breath. A diagnosis of pulmonary embolism is made. One common cause of pulmonary embolism is:
Correct Answer: C
Rationale: Deep vein thrombosis (DVT) is a common cause of pulmonary embolism, as clots from the veins (often legs) can dislodge and travel to the lungs, causing acute shortness of breath. Arteriosclerosis, aneurysms, and varicose veins are less directly associated.