NCLEX-RN
NCLEX RN Med Surg Questions Questions
Extract:
Question 1 of 5
A client with acute respiratory distress syndrome (ARDS) is showing signs of increased dyspnea. The nurse reviews a report of blood gas values that recently arrived, shown below. Which finding should the nurse report to the physician?
Correct Answer: A
Rationale: The normal range for partial pressure of arterial carbon dioxide (PaCO2) is 35 to 45 mm Hg. Thus, this client’s PaCO2 level is low. The client is experiencing respiratory alkalosis (carbonic acid defi cit) due to hyperventilation. The nurse should report this fi nding to the physician because it requires intervention. The increase in ventilation decreases the PaCO2 level, which leads to decreased carbonic acid and alkalosis. The bicarbonate level is normal in uncompensated respiratory alkalosis along with the normal PaO2 level. Normal serum pH is 7.35 to 7.45; in uncompensated respiratory alkalosis, the serum pH is greater than 7.45.
Question 2 of 5
A client who was a victim of a gunshot wound was treated in the emergency department and died. What should the nurse direct the unlicensed assistive personnel (UAP) to do during postmortem care? Select all that apply.
Correct Answer: B,D
Rationale: UAP can cover the body and transport it to the morgue. Removing tubes may be restricted due to forensic needs, and notifying family or chaplain is typically a nurse's responsibility.
Question 3 of 5
A client with pneumonia is experiencing pleuritic chest pain. The nurse should assess the client for:
Correct Answer: C
Rationale: Pleuritic chest pain is sharp or moderate and worsens with inspiration due to inflamed pleura. Constant aching, midsternal pain, or muscle spasm pain are not characteristic of pleurisy.
Question 4 of 5
A 21-year-old male client is transported by ambulance to the emergency department after a serious automobile accident. He complains of severe pain in his right chest where he struck the steering wheel. Which is the primary client goal at this time?
Correct Answer: B
Rationale: Maintaining adequate oxygenation is the primary goal in chest trauma to prevent hypoxia from pneumothorax or hemothorax. Anxiety, pain, and volume are secondary priorities.
Question 5 of 5
The nurse is checking the laboratory results of a 52-year-old client with colon cancer admitted for further chemotherapy. The client has lost 30 lb (13.6 kg) since initiation of the treatment. Which laboratory result should be reported to the health care provider?
Correct Answer: D
Rationale: A low albumin level (2.8 g/dL) indicates malnutrition, which is concerning given the client's significant weight loss and needs to be reported for nutritional intervention.