NCLEX-RN
NCLEX RN Medical Surgical Practice Questions Questions
Extract:
Question 1 of 5
A client is receiving vincristine (Oncovin). Client teaching by the nurse should include instructions on:
Correct Answer: D
Rationale: Vincristine commonly causes constipation due to neurotoxicity. A bowel regimen (e.g., stool softeners, laxatives) is essential to prevent and manage this side effect.
Question 2 of 5
The nurse is to administer an antibiotic to a client with burns now, but there is no medication in the client's medication box. What should the nurse do first?
Correct Answer: C
Rationale: Calling the pharmacy ensures timely delivery of the correct medication, maintaining safety and adherence to protocol. Borrowing medication is unsafe and unethical.
Question 3 of 5
A male client who has been taking warfarin (Coumadin) has been admitted with severe acute rectal bleeding and the following laboratory results: International Normalized Ratio (INR), 8; hemoglobin, 11 g/dL; and hematocrit, 33%. Which of the following physician orders should the nurse expect to implement initially? Select all that apply.
Correct Answer: C,D
Rationale: An INR of 8 indicates excessive anticoagulation from warfarin, causing severe bleeding. Initial management includes administering fresh frozen plasma (FFP) to replace clotting factors and vitamin K to reverse warfarin's effects. Dextrose/saline, sigmoidoscopy preparation, and enemas are not immediate priorities.
Question 4 of 5
The nurse is assessing a client with cirrhosis who has developed hepatic encephalopathy. The nurse should notify the physician of a decrease in which lab serum that is a potential precipitating factor for hepatic encephalopathy?
Correct Answer: C
Rationale: Hypokalemia (
C) increases ammonia production, precipitating hepatic encephalopathy. Aldosterone (
A), creatinine (
B), and protein (
D) are not directly linked to this condition's onset.
Question 5 of 5
The nurse is assessing a client who has a chest tube connected to a water-seal chest tube drainage system. According to the illustrationshown, which should the nurse do?
Correct Answer: D
Rationale:
To promote chest tube drainage the drainage system must be lower than the client's lungs. The amount of drainage is not abnormal; it is not necessary to notify the physician. The nurse should chart the amount and color of drainage every 4 to 8 hours.