NCLEX-RN
Med Surg RN NCLEX Practice Questions Questions
Extract:
Question 1 of 5
A client with acute renal failure has an increase in the serum potassium level. The nurse should monitor the client for:
Correct Answer: A
Rationale: Elevated potassium can cause cardiac arrhythmias, potentially leading to cardiac arrest, requiring close monitoring.
Question 2 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?
Order the Items
Source Container
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 3 of 5
A client is to receive epoetin (Epogen) injections. What laboratory value should the nurse assess before giving the injection?
Correct Answer: A
Rationale: Epoetin (Epogen) stimulates red blood cell production and is used to treat anemia. The nurse should assess hematocrit before administration to evaluate the client's response to therapy and ensure levels do not rise excessively, which can increase the risk of hypertension or thrombosis. Hemoglobin is also relevant but hematocrit is more commonly monitored. Coagulation times are not directly affected by epoetin.
Question 4 of 5
Which clinical manifestations should the nurse expect to assess in a client diagnosed with an overdose of a cholinergic agent?
Correct Answer: B,C,D
Rationale: Cholinergic overdose (e.g., organophosphates) causes urinary incontinence (
B), CNS depression (
C), and seizures (
D) due to excessive acetylcholine. Dry mucous membranes and skin rash are not typical.
Question 5 of 5
When teaching a client newly diagnosed with primary Addison's disease, the nurse should explain that the disease results from:
Correct Answer: C
Rationale: Primary Addison's disease is caused by idiopathic adrenal gland atrophy, leading to deficient cortisol and aldosterone production.