NCLEX-RN
Medical Surgical Nursing NCLEX RN Questions Questions
Extract:
Question 1 of 5
In developing a teaching plan for the client with a hiatal hernia, the nurse's assessment of which work-related factors would be most useful?
Correct Answer: B
Rationale: Poor body mechanics during lifting can increase intra-abdominal pressure, exacerbating hiatal hernia symptoms, making this the most relevant work-related factor.
Question 2 of 5
The client is to take nothing by mouth after 4 a.m. The nurse recognizes that the client has deficient knowledge when he states that he:
Correct Answer: D
Rationale: Smoking after 4 a.m. violates the nothing-by-mouth (NPO) order, as it introduces substances into the body and can affect anesthesia safety. The other actions either comply with NPO (brushing teeth without swallowing, holding a washcloth) or occurred before the cutoff (gelatin at 3:30 a.m.).
Question 3 of 5
A 250-lb male client recovering from general anesthesia has the following assessment findings: pulse, 150 bpm; blood pressure, 90/50 mm Hg; respiratory rate, 28 breaths/minute; tympanic temperature, 99.8°F (37.7°C); and rigid muscles. The nurse determines that the client is:
Correct Answer: C
Rationale: Tachycardia, hypotension, tachypnea, and muscle rigidity suggest malignant hyperthermia, a life-threatening reaction to anesthesia. Immediate action, including emergency medications like dantrolene, is required.
Question 4 of 5
A client with peripheral vascular disease has chronic, severe pretibial and ankle edema bilaterally. Because the client is on complete bed rest and circulation is compromised, one goal is to maintain tissue integrity. Which of the following interventions will help achieve this outcome?
Correct Answer: C
Rationale: Turning the client every 1 to 2 hours prevents pressure ulcers by relieving pressure on dependent areas, promoting circulation, and maintaining skin integrity in a client with PVD and edema on bed rest. Pain medication, fluids, and hygiene are important but do not directly address tissue integrity.
Question 5 of 5
A client with peripheral vascular disease and chronic obstructive pulmonary disease takes theophylline (Theo-Dur) 200 mg twice daily every day. The physician is considering adding pentoxifylline (Trental) to the regimen. The nurse should be aware that:
Correct Answer: B
Rationale: Pentoxifylline may increase theophylline levels by inhibiting its metabolism, potentially leading to toxicity (e.g., nausea, tachycardia). The nurse should monitor theophylline levels and symptoms. Bleeding risk, severe hypotension, or contraindication are not documented interactions.