NCLEX-RN
NCLEX RN Medical Surgical Questions and Answers Questions
Extract:
Question 1 of 5
A client has been admitted to the coronary care unit. The nurse observes third-degree heart block at a rate of 35 bpm on the client's cardiac monitor. The client has a blood pressure of 90/60. The nurse should take which of the following actions first?
Correct Answer: A
Rationale: Third-degree heart block with a rate of 35 bpm and hypotension requires immediate transcutaneous pacing to restore adequate heart rate and perfusion.
Question 2 of 5
A client has an amylase level of 450 units/L and lipase level of 659 units/L. The client has mid-epigastric pain with nausea. What assessment helps the nurse to determine severity of the client's condition?
Correct Answer: A
Rationale: Ranson's criteria (
A) assess pancreatitis severity using clinical and lab parameters like age, glucose, and white blood cell count. Vital signs (
B) and urine output (
C) are general but less specific. Glasgow Coma Scale (
D) is for neurological assessment, not pancreatitis severity.
Question 3 of 5
Which of the following has been identified as a potential risk factor for the development of colon cancer?
Correct Answer: D
Rationale: A history of inflammatory bowel disease is a risk factor for colon cancer. Other risk factors include age (older than 40 years), history of familial polyposis, colorectal polyps, and high-fat or low-fiber diet. CN: Reduction of risk potential; CL: Analyze
Question 4 of 5
Which symptom suggests worsening neurological status in a client with a head injury?
Correct Answer: B
Rationale: Decreased pulse rate (bradycardia) may indicate increased intracranial pressure, a sign of worsening neurological status.
Question 5 of 5
Which of the following reflects the principle on which a client's diet will most likely be based during the acute phase of myocardial infarction?
Correct Answer: B
Rationale: Small, easily digested meals reduce the metabolic demand on the heart and prevent gastrointestinal distress, which could exacerbate myocardial oxygen demand during the acute phase of MI.