NCLEX-RN
NCLEX RN Questions Medical Surgical Nursing Questions
Extract:
Question 1 of 5
A client is discharged after being hospitalized for thrombophlebitis. She will be driving home with her daughter, who lives 2 hours away. During the 2-hour ride, the nurse should advise the client to:
Correct Answer: B
Rationale: Ankle pumps and foot range-of-motion exercises during the car ride promote venous return, preventing stasis and recurrent thrombophlebitis. Arm circles are irrelevant, elevating legs is impractical, and an ambulance is unnecessary for a discharged client.
Question 2 of 5
A client is receiving fluid replacement with Lactated Ringer's after 40% of his body was burned 10 voluto hours ago. The assessment reveals: temperature 36.2°C; heart rate 122; blood pressure 84/42; CVP 2 mm Hg; and urine output 25 mL for the last 2 hours. The I.V. rate is currently at 375 mL/hour. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse calls the healthcare provider with the recommendation for:
Correct Answer: C
Rationale: Low blood pressure, high heart rate, low CVP, and inadequate urine output indicate hypovolemia. Increasing the I.V. rate is appropriate to improve fluid resuscitation, as per burn fluid management protocols.
Question 3 of 5
The nurse is planning care for a client who had surgery for abdominal aortic aneurysm repair 2 days ago. The pain medication and the use of relaxation and imagery techniques are not relieving the client's pain and the client refuses to get out of bed to ambulate as ordered. The nurse contacts the physician, explains the situation, and provides information about drug dose, frequency of administration, the client's vital signs, and the client's score on the pain scale. The physician tells the nurse that the current order for pain medication is sufficient and the client will be fine in a few days. The nurse should next:
Correct Answer: A
Rationale: The nurse should advocate for the client by reiterating to the physician that the current pain management is ineffective, preventing ambulation, which is critical for recovery post-AAA repair. This aligns with ethical and professional standards. Asking another provider, waiting, or reporting to the team leader delays care.
Question 4 of 5
A client is to receive enoxaparin (Lovenox) 6 hours before the scheduled time of her laparoscopic vaginal assisted hysterectomy. Which of the following effects does the nurse recognize as an intended therapeutic action of the enoxaparin?
Correct Answer: B
Rationale: Enoxaparin is an anticoagulant that prevents postoperative thrombi by inhibiting clot formation, reducing the risk of deep vein thrombosis or pulmonary embolism.
Question 5 of 5
The nurse identifies deficient knowledge when the client undergoing induction therapy for leukemia makes which of the following statements?
Correct Answer: B
Rationale: During leukemia induction therapy, the client is at high risk for infection due to neutropenia. Pets like cats can carry pathogens (e.g.,
Toxoplasma), and the statement about returning to a cat indicates a knowledge deficit about infection risks. The other statements reflect appropriate self-care measures.