NCLEX-RN
Med Surg RN NCLEX Practice Questions Questions
Extract:
Question 1 of 5
A nurse should interpret which of the following as an early sign of a tension pneumothorax in a client with chest trauma?
Correct Answer: C
Rationale: Respiratory distress is an early sign of tension pneumothorax due to increasing intrathoracic pressure. Diminished breath sounds and tracheal deviation are later signs. 'Skilled heart sounds' is likely a typo and unclear.
Question 2 of 5
A client is admitted from the emergency department after falling down a flight of stairs at home. Her vital signs are stable and her history states that she had a gastric stapling 2 years ago and takes neomycin for acne. The client jokes about how she is clumsy lately and trips over things. The nurse should ask the client which of the following questions? Select all that apply.
Correct Answer: A,B,D
Rationale: Gastric stapling can impair vitamin B12 absorption, and neomycin may further reduce B12 levels by altering gut flora. The client's clumsiness and falls suggest possible B12 deficiency neuropathy, warranting questions about numbness and B12 intake. Asking about safety at home is crucial to assess for environmental or abuse-related causes of falls. Depression and iron intake are less directly related to the symptoms described.
Question 3 of 5
A 15-year-old client needs life-saving emergency surgery, but his relatives live an hour away from the hospital and cannot sign the consent form. What is the nurse's best response?
Correct Answer: B
Rationale: For life-saving emergency surgery in a minor, telephone consent from the family with a witness is acceptable to meet legal requirements while expediting care.
Question 4 of 5
What is a priority nursing intervention for a client with renal colic?
Correct Answer: B
Rationale: Morphine effectively manages severe renal colic pain, prioritizing client comfort.
Question 5 of 5
A priority goal for the hospitalized client who 2 days earlier had a total laryngectomy with creation of a new tracheostomy would be to:
Correct Answer: D
Rationale: Maintaining a patent airway is the priority goal post-laryngectomy with a new tracheostomy to ensure adequate oxygenation and prevent respiratory distress.