NCLEX-RN
NCLEX RN Medical Surgical Practice Questions Questions
Extract:
Question 1 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.
Question 2 of 5
The nurse is developing a discharge teaching plan for a client who underwent a repair of abdominal aortic aneurysm 4 days ago. The nurse reviews the client's chart for information about the client's history. Key findings are noted in the chart below. Based on the data and expected outcomes, which should the nurse emphasize in the teaching plan?
Correct Answer: D
Rationale: Post-AAA repair, tissue perfusion is critical to ensure graft patency and prevent ischemia in the lower extremities or organs. Teaching should emphasize signs of poor perfusion (e.g., pain, pallor, pulselessness) and follow-up care. Food, fluid, and skin integrity are less urgent.
Question 3 of 5
The nurse is obtaining a blood sample for a PTT test ordered for a client who is taking heparin. It is 5 a.m. When drawing the blood, the nurse should do which of the following? Select all that apply.
Correct Answer: B,C,E
Rationale: Rationales:
B) Checking the armband ensures correct client identification, critical for safety.
C) Labeling the vial in front of the client prevents errors. E) Asking the client to state their name confirms identity.
A) Awakening the client is unnecessary if asleep, as the draw can be done gently.
D) Room number is unreliable for identification.
Question 4 of 5
A physician orders vitamin B12 for a client with pernicious anemia. Which site is appropriate for the nurse to administer vitamin B12? Select all that apply.
Correct Answer: A,D,F
Rationale: Vitamin B12 is administered intramuscularly, and appropriate sites include the deltoid, ventrogluteal, and dorsogluteal muscles, as these provide adequate muscle mass for absorption. The greater femur trochanter and acromion muscle are not standard injection sites, and the upper back is not suitable for intramuscular injections.
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.