NCLEX-RN
NCLEX RN Medical Surgical Questions and Answers Questions
Extract:
Question 1 of 5
A nurse has two clients that have an order to receive a blood transfusion of packed red blood cells at the same time. The first client's blood pressure dropped from the preoperative value of 120/80 mm Hg to a postoperative value of 100/50. The second client is 58 years old and is hospitalized because he developed dehydration and anemia following pneumonia. After checking the patency of their I.V. lines and vital signs, which should the nurse do next?
Correct Answer: C
Rationale: The first client's significant blood pressure drop (120/80 to 100/50) indicates potential hypovolemia or bleeding, making their transfusion a priority to restore volume and oxygen-carrying capacity. The second client's condition is less urgent. The nurse should call for and hang the first client's transfusion first.
Question 2 of 5
Which nursing intervention has been found to be the most effective means of preventing plantar flexion in a client who has had a stroke with residual paralysis?
Correct Answer: A
Rationale: A firm footboard maintains the foot in a neutral position, preventing plantar flexion contractures. Repositioning, shoes, or massage are less effective for this specific purpose.
Question 3 of 5
To decrease intraocular pressure following cataract surgery, the nurse should instruct the client to avoid:
Correct Answer: B
Rationale: Coughing increases intraocular pressure by causing a Valsalva maneuver, which can strain the surgical site and lead to complications like hemorrhage or wound dehiscence.
Question 4 of 5
Which of the following would be a significant intervention to help prevent lung cancer?
Correct Answer: B
Rationale: Smoking cessation is the most effective intervention to prevent lung cancer, as smoking is the leading cause. Screening (not 'access to drugs'), asbestos checks, and air cleaners are less impactful.
Question 5 of 5
Which symptom suggests worsening neurological status in a client with a head injury?
Correct Answer: B
Rationale: Decreased pulse rate (bradycardia) may indicate increased intracranial pressure, a sign of worsening neurological status.