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NCLEX RN Questions Medical Surgical Nursing Questions

Extract:

The nurse in the emergency department (ED) is caring for a 62-year-old male client.
Item 5 of 6
Triage Note
1700:
• The client was brought to the ED after collapsing on a tennis court.
• Vital signs: BP 94/57, T 105° F (40.5° C), P 115, RR 26, Pulse oximetry 95% on room air. • The client is lethargic and confused. Skin is pale, and there is some perspiration on the forehead. Thready peripheral pulses, clear lung fields bilaterally, tachypnea, shallow respirations.


Question 1 of 5

Click to highlight the orders that the nurse should consider a priority.

Correct Answer: B,C,D,F,G

Rationale: Priority orders address immediate life-threatening issues: removing clothing (
B), IV access (
C), saline (
D), temperature catheter (F), and cooling blanket (G) manage heat stroke and hypotension. Medication reconciliation (
A) and medical records (E) are secondary.

Extract:


Question 2 of 5

Correct Answer:

Rationale:

Question 3 of 5

Correct Answer:

Rationale:

Question 4 of 5

Correct Answer:

Rationale:

Question 5 of 5

Correct Answer:

Rationale:

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