NCLEX-RN
Med Surg RN NCLEX Questions Questions
Extract:
Question 1 of 5
A client with a hemorrhagic stroke is slightly agitated, heart rate is 118, respirations are 22, bilateral rhonchi are auscultated, SpO2 is 94%, blood pressure is 144/88, and oral secretions are noted. What order of interventions should the nurse follow when suctioning the client to prevent increased intracranial pressure (ICP) and maintain adequate cerebral perfusion?
Correct Answer: B,D,A,C
Rationale: The correct order is: 1) Hyperoxygenate to prevent hypoxia (
B); 2) Provide sedation to reduce agitation and ICP spikes (
D); 3) Suction the airway to clear secretions (
A); 4) Suction the mouth to remove residual secretions (
C). This sequence minimizes ICP increases and ensures oxygenation.
Question 2 of 5
Which of the following actions should the nurse plan to do first when caring for a client who is experiencing spiritual distress?
Correct Answer: D
Rationale: Helping the client explore their own values and beliefs is the first step in addressing spiritual distress, as it establishes a foundation for personalized spiritual support.
Question 3 of 5
A client receives fibrinolytic therapy upon admission following a myocardial infarction. He is now receiving an I.V. infusion of heparin sodium at 1,200 units/hour. The dilution is 25,000 units/500 mL. How many milliliters per hour will this client receive?
Correct Answer: 24 mL/hour
Rationale:
To calculate: (1,200 units/hour ÷ 25,000 units) × 500 mL = 24 mL/hour. This is a calculation question, not multiple-choice, so no choices or correct answer letter is provided.
Question 4 of 5
What should the nurse do first when a client with a head injury begins to have clear drainage from his nose?
Correct Answer: C
Rationale: Clear drainage from the nose after a head injury may indicate cerebrospinal fluid (CSF) leakage, a serious condition. The priority is to collect the fluid for analysis to confirm CSF and avoid infection, making providing tissues the first action. Compressing the nares or tilting the head back could increase intracranial pressure or contaminate the fluid, and an antihistamine is inappropriate without confirming the cause.
Question 5 of 5
Which of the following should the nurse assess when completing the history and physical examination of a client diagnosed with osteoarthritis?
Correct Answer: D
Rationale: Local joint pain is a primary symptom of osteoarthritis, resulting from cartilage degeneration.