NCLEX-RN
Med Surg RN NCLEX Practice 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
When suctioning a tracheostomy or laryngectomy tube, the nurse should follow which of the following procedures?
Correct Answer: A
Rationale: Using a sterile catheter each time minimizes infection risk in the airway. Reusing catheters, even if cleaned, increases infection risk.
Question 3 of 5
A client is in balanced suspension traction using a half-ring Thomas splint with a Pearson attachment that suspends the lower extremity and applies direct skeletal traction for a hip fracture. Which of the following nursing assessments would not be appropriate?
Correct Answer: C
Rationale: Neurovascular checks proximal to the splint are less relevant, as distal checks assess circulation and nerve function affected by the fracture and traction.
Question 4 of 5
The client with acute renal failure asks the nurse for a snack. Because the client's potassium level is elevated, which of the following snacks is most appropriate?
Correct Answer: A
Rationale: Gelatin dessert is low in potassium, suitable for a client with hyperkalemia, unlike yogurt, oranges, or peanuts.
Question 5 of 5
A physician orders a lengthy X-ray examination for a client with osteoarthritis. Which of the following actions by the nurse would demonstrate client advocacy?
Correct Answer: A
Rationale: Dividing the session into shorter ones reduces discomfort, advocating for the client's comfort while ensuring the test is completed.