NCLEX-RN
Medical Surgical Nursing NCLEX RN Questions Questions
Extract:
Question 1 of 5
A client had a colectomy 8½ hours ago. She has received 1,500 mL of dextrose 5% in water with normal saline solution. The client has just used a patient-controlled analgesia pump to administer morphine for pain, has been repositioned for comfort, and has stable pulse rate, respirations, and blood pressure. What should the nurse do next?
Correct Answer: B
Rationale: Morphine can cause respiratory depression or hypotension. Assessing vital signs after PCA use ensures the client's safety and detects adverse effects promptly.
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
The nurse reviews an arterial blood gas report for a client with chronic obstructive pulmonary disease (COPD). pH 7.35; PCO2 62; PO2 70; HCO3 34. The nurse should:
Correct Answer: B
Rationale: The ABG shows compensated respiratory acidosis (normal pH, high PCO2, high HCO3) with mild hypoxemia (PO2 70). Assessing vital signs evaluates stability before escalating care. A non-rebreather mask or intubation is premature. Repositioning may help but is less urgent.
Question 4 of 5
The nurse is planning care for a group of clients who have had total hip replacement. Of the clients listed below, which is at highest risk for infection and should be assessed first?
Correct Answer: C
Rationale: Periodontal disease increases infection risk due to potential bacterial spread to the prosthesis.
Question 5 of 5
The nurse is assessing a client who has had a myocardial infarction (MI). The nurse notes the cardiac rhythm shown on the electrocardiogram strip below. The nurse identifi es this rhythm as which of the following?
Correct Answer: C
Rationale: PVCs are early depolarizations originating in the ventricles, and they present exactly as seen in your strip.