NCLEX-RN
Free NCLEX RN Questions for Med Surg Questions
Extract:
Question 1 of 5
A nurse assesses a 40-year-old female client with vasospastic disorder (Raynaud's phenomenon) involving her right hand. The nurse notes the information in the progress notes, as shown below. From these findings, the nurse should formulate which priority nursing diagnosis?
Correct Answer: C
Rationale: Ineffective tissue perfusion (peripheral) is the priority nursing diagnosis in Raynaud's phenomenon, as vasospasm reduces blood flow to the extremities, causing ischemia. This underlies symptoms like numbness or pallor. Pain, sensory changes, or skin integrity risks are secondary to perfusion deficits.
Question 2 of 5
A client with pneumonia has a temperature of 102.6°F (39.2°C), is diaphoretic, and has a productive cough. The nurse should include which of the following measures in the plan of care?
Correct Answer: C
Rationale: Diaphoresis from fever causes damp linens, which can lead to discomfort and skin breakdown; frequent linen changes are needed. Position changes aid lung expansion but are less urgent. Suctioning is invasive and not routinely required. Bedpan use depends on mobility, not fever.
Question 3 of 5
While caring for a client who has sustained a myocardial infarction (MI), the nurse notes eight premature ventricular contractions (PVCs) in 1 minute on the cardiac monitor. The client is receiving an I.V. infusion of 5% dextrose in water (D5W) and oxygen at 2 L/minute. The nurse's first course of action should be:
Correct Answer: B
Rationale: Frequent PVCs (eight per minute) may indicate irritability of the myocardium, risking serious arrhythmias. Notifying the physician promptly ensures timely intervention, such as antiarrhythmic therapy.
Question 4 of 5
A nurse is developing a care plan for a client with hepatic encephalopathy. Which of the following are goals for the care for this client? Select all that apply.
Correct Answer: A,B
Rationale: Preventing constipation (
A) and administering lactulose (
B) reduce ammonia levels, key in managing hepatic encephalopathy. Coordination (
C) and pupil reaction (
D) are unrelated. High carbohydrates (E) and physical activity (F) are not primary goals.
Question 5 of 5
A client post-inguinal herniorrhaphy reports scrotal swelling 24 hours after surgery. Which action should the nurse take first?
Correct Answer: C
Rationale: Elevating the scrotum and applying ice is the first action to reduce scrotal swelling post-inguinal herniorrhaphy, a common postoperative finding. Warm compresses may worsen swelling, notification is needed if swelling persists, and diuretics are not indicated. CN: Physiological adaptation; CL: Synthesize