NCLEX-RN
NCLEX RN Medical Surgical Questions and Answers Questions
Extract:
Question 1 of 5
Glulisine (Apidra) insulin is ordered to be administered to a client before each meal. To assist the day-shift nurse who is receiving the report, the night-shift nurse gives the morning dose of glulisine. When the day-shift nurse goes to the room of the client who requires glulisine, the nurse finds that the client is not in the room. The client's roommate tells the nurse that the client 'went for a test.' What should the nurse do next?
Correct Answer: A
Rationale: Glulisine is rapid-acting insulin, and the client must eat within 15 minutes to prevent hypoglycemia. The nurse should locate the client and provide juice to counteract potential hypoglycemia.
Question 2 of 5
A client has been admitted to the coronary care unit. The nurse observes third-degree heart block at a rate of 35 bpm on the client's cardiac monitor. The client has a blood pressure of 90/60. The nurse should take which of the following actions first?
Correct Answer: A
Rationale: Third-degree heart block with a rate of 35 bpm and hypotension requires immediate transcutaneous pacing to restore adequate heart rate and perfusion.
Question 3 of 5
The nurse is caring for a client who is using a portable wound suction unit (see figure). Six hours following surgery, the drainage unit is full. The nurse should do which of the following?
Correct Answer: C
Rationale: Portable wound suction units can be emptied and drained. The nurse should compress the unit after emptying to create suction before reinserting the plug. It is normal for the suction unit to be full six hours after surgery, and the nurse does not need to notify the surgeon. The drainage unit should be emptied when full or every 8 hours. The drain in the incision should remain in place until the surgeon removes it. While all drainage should be noted as output on the chart, recording the amount without emptying the drainage unit is not accurate nor is it safe practice.
Question 4 of 5
A female client who has a urinary diversion tells the nurse, 'This urinary pouch is embarrassing. Everyone will know that I'm not normal. I don't see how I can go out in public anymore.' The most appropriate nursing diagnosis for this client is:
Correct Answer: D
Rationale: The client's statement reflects distress about the urinary diversion's impact on her appearance and social life, indicating a disturbed body image.
Question 5 of 5
A client is newly diagnosed with cancer and is beginning a treatment plan. Which of the following nursing interventions will be most effective in helping the client cope?
Correct Answer: D
Rationale: Identifying available resources (e.g., support groups, counseling) empowers the client to cope with the emotional and practical challenges of a new cancer diagnosis.