NCLEX-RN
NCLEX RN Medical Surgical Practice Questions Questions
Extract:
Question 1 of 5
A client with chest pain is prescribed intravenous nitroglycerin (Tridil). Which assessment is of greatest concern for the nurse initiating the nitroglycerin drip?
Correct Answer: B
Rationale: Nitroglycerin causes vasodilation, which can lower blood pressure. A blood pressure of 88/46 indicates hypotension, a significant concern as it may compromise perfusion, making it the priority assessment.
Question 2 of 5
On the day of surgery, a client with diabetes who takes insulin on a sliding scale is ordered to have nothing by mouth and all medications withheld. The client's 6 a.m. glucose level is 300 mg/dL. The nurse should:
Correct Answer: C
Rationale: A glucose level of 300 mg/dL indicates significant hyperglycemia, which poses risks during surgery. Calling the physician for specific orders ensures appropriate insulin administration while adhering to NPO and surgical protocols.
Question 3 of 5
The nurse is obtaining a blood sample for a PTT test ordered for a client who is taking heparin. It is 5 a.m. When drawing the blood, the nurse should do which of the following? Select all that apply.
Correct Answer: B,C,E
Rationale: Rationales:
B) Checking the armband ensures correct client identification, critical for safety.
C) Labeling the vial in front of the client prevents errors. E) Asking the client to state their name confirms identity.
A) Awakening the client is unnecessary if asleep, as the draw can be done gently.
D) Room number is unreliable for identification.
Question 4 of 5
The nurse is to Ros instill drops of phenylephrine hydrochloride (Neo-Synephrine) into the client's eye prior to cataract surgery. Which of the following is the expected outcome?
Correct Answer: B
Rationale: Phenylephrine hydrochloride (Neo-Synephrine) is a sympathomimetic agent used to dilate the pupil (mydriasis) by stimulating the dilator muscle of the iris and to constrict blood vessels, reducing conjunctival redness and swelling before cataract surgery.
Question 5 of 5
The client with an above-the-knee amputation is to use crutches while his prosthesis is being adjusted. In which of the following exercises should the nurse instruct the client to best prepare him for using crutches?
Correct Answer: B
Rationale: Isometric shoulder exercises strengthen the upper body, essential for crutch walking.