NCLEX-RN
Medical Surgical NCLEX RN Questions
Extract:
Question 1 of 5
A client with ascites and peripheral edema is at risk for impaired skin integrity. To prevent skin breakdown, the nurse should:
Correct Answer: C
Rationale: An alternating air pressure mattress (
C) prevents pressure ulcers in clients with edema. ROM exercises (
A) and elevation (
D) are helpful but secondary. Abdominal massage (
B) is not indicated.
Question 2 of 5
A client who has had a total hip replacement has a dislocated hip prosthesis. The nurse should first?
Correct Answer: D
Rationale: Notifying the surgeon is the priority, as dislocation requires urgent medical intervention.
Question 3 of 5
Which of the following symptoms might indicate that a client was developing tetany after a subtotal thyroidectomy?
Correct Answer: B
Rationale: Tetany, caused by hypocalcemia from parathyroid gland damage during thyroidectomy, presents with tingling in the fingers, muscle cramps, or spasms.
Question 4 of 5
A client has the following arterial blood gas values: pH, 7.52; PaO2, 50 mm Hg; PaCO2, 28 mm Hg; HCO3ˆ’, 24 mEq/L. The nurse determines that which of the following is a possible cause for these findings?
Correct Answer: D
Rationale: The ABG shows respiratory alkalosis (high pH, low PaCO2) and severe hypoxia (PaO2 50). Pulmonary embolus causes hypoxia and hyperventilation, matching these findings. COPD causes CO2 retention. Ketoacidosis causes metabolic acidosis. Myocardial infarction is less likely to cause this pattern.
Question 5 of 5
A nurse is caring for a client who has just returned from surgery to treat a fractured mandible. Which of the following items should always be available at this client's bedside? Select all that apply.
Correct Answer: B,D
Rationale: For a client with a wired jaw due to a fractured mandible, wire cutters are essential in case of an emergency, such as vomiting, to quickly release the wires and prevent aspiration. Suction equipment is also critical to maintain a patent airway by removing secretions or vomit. A nasogastric tube, oxygen cannula, and code cart are not routinely required at the bedside unless specifically indicated.