NCLEX-RN
Med Surg RN NCLEX Questions Questions
Extract:
Question 1 of 5
A client is on complete bed rest. The nurse should assess the client for risk for developing which of the following complications?
Correct Answer: D
Rationale: Complete bed rest increases the risk of thrombophlebitis due to venous stasis from immobility, promoting clot formation. Air embolus is rare, fat embolus is associated with fractures, and stress fractures result from repetitive trauma, not bed rest.
Question 2 of 5
A client had a repair of a thoracoabdominal aneurysm 2 days ago. Which of the following findings should the nurse consider unexpected and report to the physician immediately? The client has:
Correct Answer: D
Rationale: Weakness and numbness in the lower extremities post-thoracoabdominal aneurysm repair suggest spinal cord ischemia or graft-related complications, requiring immediate reporting. Persistent pain, elevated heart rate post-ambulation, and normal urine output are expected or less urgent.
Question 3 of 5
A client with iron deficiency anemia is refusing to take the prescribed oral iron medication because the medication is causing nausea. The nurse should do which of the following? Select all that apply.
Correct Answer: A,B,E
Rationale: Nausea and vomiting are common adverse effects of oral iron preparations. The nurse should first ask the client why she does not want to take the oral medication, and then suggest ways to decrease the nausea and vomiting. Ginger may help minimize the nausea and the client can try this remedy and evaluate its effectiveness. Iron should be taken on an empty stomach but can be taken with orange juice to enhance absorption and potentially reduce nausea. The client can evaluate if this helps the nausea. Stool softeners are not typically recommended for iron deficiency anemia, as constipation is better managed with a high-fiber diet. Intramuscular iron is a last resort and not appropriate unless oral administration is ineffective.
Question 4 of 5
A client returned home from an overseas tour of duty and tells the nurse he is always tired. He has a temperature of 99.5°F (37.5°C). His skin is dark bronze, and his urine has a dark color. His hemoglobin level is 9 g/dL; his hematocrit is 49, and red blood cells are 2.75 million/µL. What should the nurse do first?
Correct Answer: B
Rationale: The client's symptoms (fatigue, bronze skin, dark urine, low hemoglobin, and RBC count) suggest hemolytic anemia, possibly due to an infectious or toxic exposure overseas. Placing the client on bed rest is the priority to reduce oxygen demand and prevent further hemolysis while diagnostic evaluation proceeds. Intake/output monitoring, isolation, and sunlight avoidance are not immediate priorities.
Question 5 of 5
When beginning I.V. erythropoietin (Epogen, Procrit) therapy, the nurse should do which of the following? Select all that apply.
Correct Answer: A,C,D,F
Rationale: For IV erythropoietin therapy, the nurse should check hemoglobin levels to monitor response and prevent overcorrection, keep multidose vials refrigerated to maintain stability, administer without mixing with other medications to avoid interactions, and educate about avoiding hazardous activities due to potential side effects like dizziness. Shaking the vial can denature the protein, and dose adjustments are typically based on hematologic response, not blood pressure.