NCLEX-RN
Free NCLEX RN Questions for Med Surg Questions
Extract:
Question 1 of 5
A client who has had her jaws wired begins to vomit. What should be the nurse's first action?
Correct Answer: C
Rationale: Suctioning the airway is the first action to prevent aspiration in a client with wired jaws who is vomiting. Cutting the wires is a last resort, and the other options do not address the immediate risk of airway obstruction.
Question 2 of 5
While caring for a client who has sustained a myocardial infarction (MI), the nurse notes eight premature ventricular contractions (PVCs) in 1 minute on the cardiac monitor. The client is receiving an I.V. infusion of 5% dextrose in water (D5W) and oxygen at 2 L/minute. The nurse's first course of action should be:
Correct Answer: B
Rationale: Frequent PVCs (eight per minute) may indicate irritability of the myocardium, risking serious arrhythmias. Notifying the physician promptly ensures timely intervention, such as antiarrhythmic therapy.
Question 3 of 5
The goal of nursing care for a client with acute myeloid leukemia (AML) is to prevent:
Correct Answer: D
Rationale: AML causes pancytopenia, including thrombocytopenia, increasing the risk of hemorrhage. Preventing bleeding is a primary nursing goal through measures like avoiding invasive procedures and monitoring for bleeding signs. Arrhythmias, liver, and renal failure are less immediate concerns.
Question 4 of 5
The nurse is planning care for a client with a femoral fracture who is in balanced suspension traction. Which of the following would the nurse be least likely to include in the plan of care?
Correct Answer: C
Rationale: Elevating the head of the bed beyond 25 degrees can disrupt traction alignment, making it least appropriate.
Question 5 of 5
A client who had an exploratory laparotomy 3 days ago has a white blood cell (WBC) differential with a shift to the left. The nurse instructs unlicensed personnel to report which clinical manifestation?
Correct Answer: C
Rationale: A left shift in the WBC differential indicates an increase in immature neutrophils, often due to infection. An elevated temperature is a key sign of infection and should be reported promptly. Swelling, redness, and purulent drainage are also concerning but may develop later.