NCLEX-RN
Medical Surgical Nursing NCLEX RN Questions Questions
Extract:
Question 1 of 5
A client receiving chemotherapy for metastatic colorectal cancer has had 2 days of vomiting. Assessment findings include: irregular pulse of 120, blood pressure 88/48, respiratory rate of 14, serum potassium of 2.9 mEq/L, and arterial blood gas€”pH 7.46, PCO‚‚ 45, PO‚‚ 95, bicarbonate level 29 mEq/L. Which of the following interventions is appropriate for the nurse to administer to the client?
Correct Answer: C
Rationale: Hypokalemia (2.9 mEq/L) and hypotension (88/48) due to vomiting require I.V. fluid and potassium replacement (D5 0.45% NS with KCl) to correct electrolyte imbalance and dehydration. The alkalosis (pH 7.46) does not require bicarbonate, and oral potassium is unsafe with vomiting.
Question 2 of 5
A client has renal colic due to renal lithiasis. What is the nurse's first priority in managing care for this client?
Correct Answer: D
Rationale: Severe pain from renal colic is the priority, requiring opioid analgesics for immediate relief to improve client comfort and cooperation.
Question 3 of 5
When giving discharge instructions to the client with vasospastic disorder (Raynaud's phenomenon), the nurse should explain that the expected outcome is a total of the symptoms by:
Correct Answer: C
Rationale: The expected outcome in Raynaud's is increased blood supply to the affected areas by reducing vasospasm, alleviating symptoms like numbness and pallor. Sympathetic nervous system influence, analgesia, and monoamine oxidase are not directly targeted.
Question 4 of 5
The client with rheumatoid arthritis tells the nurse, 'I have a friend who took gold shots and had a wonderful response. Why didn't my physician let me try that?' Which of the following responses by the nurse would be most appropriate?
Correct Answer: D
Rationale: Individual responses to treatments vary due to differences in disease severity, comorbidities, and side effect profiles. This response educates the client without dismissing their concerns.
Question 5 of 5
Which assessment is most important for a client with a traumatic brain injury?
Correct Answer: A
Rationale: The Glasgow Coma Scale is critical to assess neurological status and guide management in traumatic brain injury.