NCLEX-RN
Medical Surgical NCLEX RN Questions
Extract:
Question 1 of 5
A client has a Jackson-Pratt drainage tube in place the first day after surgical repair of a ruptured diverticulum. The client asks the nurse the purpose of the drain. What is the nurse's best response?
Correct Answer: A
Rationale: A Jackson-Pratt drain removes fluid and blood from the surgical site, preventing infection in the peritoneal cavity by reducing fluid accumulation post-diverticulum repair.
Question 2 of 5
Thirty people are injured in a train derailment. Ineffective and the transported to the hospital first?
Correct Answer: D
Rationale: A sucking chest wound is a life-threatening condition that can impair breathing and requires immediate intervention, prioritizing this patient for transport over others with less urgent injuries.
Question 3 of 5
A client is admitted to the unit with a diagnosis of thrombophlebitis and deep vein thrombosis of the right leg. A loading dose of heparin has been given in the emergency room, and I.V. heparin will be continued for the next several days. The nurse should develop a plan of care for this client that will involve:
Correct Answer: D
Rationale: Heparin therapy for DVT requires monitoring aPTT to ensure therapeutic anticoagulation (1.5–2.5 times baseline). INR is less relevant for heparin but may be monitored if transitioning to warfarin. Aspirin is not typically used, and green leafy vegetables (high in vitamin K) may affect warfarin, not heparin.
Question 4 of 5
The nurse is obtaining the pulse of a client who has had a femoral-popliteal bypass surgery 6 hours ago. Which assessment provides the most accurate information about the client's postoperative status?
Correct Answer: B
Rationale: Assessing the pedal pulse post-femoral-popliteal bypass is most accurate for evaluating graft patency and distal perfusion. A palpable or Doppler-detected pedal pulse indicates successful restoration of blood flow to the lower extremity. Other pulses (radial, brachial, popliteal) are less specific to the surgical site.
Question 5 of 5
A client who has had a lumbar laminectomy with a spinal fusion is sitting in a chair. In which position are his feet if he is complying with his postoperative instructions?
Correct Answer: A
Rationale: Feet flat on the floor maintain neutral spine alignment, reducing strain on the surgical site.