NCLEX-RN
Free NCLEX RN Questions for Med Surg Questions
Extract:
Question 1 of 5
A nurse is assessing a client with heart failure. The nurse should assess the client based on which compensatory mechanisms that are activated in the presence of heart failure? Select all that apply.
Correct Answer: A,B,C,D,E
Rationale: Heart failure activates the sympathetic nervous system (
A), renin-angiotensin-aldosterone system (
B), myocardial hypertrophy (
C), natriuretic peptide release (
D), and ventricular dilation (E) to compensate for reduced cardiac output.
Question 2 of 5
A client has acute arterial occlusion. The physician has ordered a thrombolytic agent. Before starting the medication, the nurse should:
Correct Answer: A
Rationale: Before administering a thrombolytic agent for acute arterial occlusion, the nurse must review coagulation lab values (e.g., aPTT, INR, platelets) to assess bleeding risk, as thrombolytics increase hemorrhage potential. Stool testing, pulse counting, and urine output are secondary or unrelated.
Question 3 of 5
A client with acute respiratory distress syndrome (ARDS) has fine crackles at lung bases and the respirations are shallow at a rate of 28 breaths/minute. The client is restless and anxious. In addition to monitoring the arterial blood gas results, the nurse should do which of the following? Select all that apply.
Correct Answer: C,D
Rationale: Administering humidified oxygen (
C) improves oxygenation in ARDS. Auscultating lungs (
D) monitors crackles and ventilation. Creatinine/BUN monitoring is unrelated to acute respiratory status. Sedatives may depress respiration.
Question 4 of 5
The client has had hypertension for 20 years. The nurse should assess the client for?
Correct Answer: A
Rationale: Long-standing hypertension damages kidneys, leading to renal insufficiency or failure, a common complication requiring assessment.
Question 5 of 5
A client with Parkinson's disease needs a long time to complete her morning hygiene, but she becomes annoyed when the nurse offers assistance and refuses all help. Which action is the nurse's best initial response in this situation?
Correct Answer: B
Rationale: Praising independence and providing extra time respects the client's autonomy while supporting her efforts. Forcing help, labeling her unrealistic, or suggesting modifications may undermine her dignity.