NCLEX-RN
NCLEX RN Med Surg Questions Questions
Extract:
Question 1 of 5
Initial treatment for a cerebrospinal fluid (CSF) leak after transsphenoidal hypophysectomy would most likely involve:
Correct Answer: C
Rationale: Bed rest with head elevation reduces pressure on the surgical site, promoting healing of a CSF leak.
Question 2 of 5
A client is receiving an I.V. infusion of 5% dextrose in water (D5W). The skin around the I.V. insertion site is red, warm to touch, and painful. The nurse should first:
Correct Answer: C
Rationale: Redness, warmth, and pain at the I.V. site indicate phlebitis or infiltration. The first action is to discontinue the I.V. to prevent further tissue damage. Changing fluids, applying a compress, or giving acetaminophen does not address the immediate issue.
Question 3 of 5
A client is admitted to the emergency department complaining of severe abdominal pain. A radiograph reveals a large abdominal aortic aneurysm. The primary goal at this time is to:
Correct Answer: C
Rationale: A large abdominal aortic aneurysm with severe pain suggests impending rupture, requiring emergency surgery to prevent catastrophic bleeding. Preparing the client for surgery is the primary goal, as it addresses the life-threatening condition. Circulation, pain, and breathing exercises are managed perioperatively.
Question 4 of 5
A 65-year-old client is admitted to the emergency department with a fractured hip. The client has chest pain and shortness of breath. The health care provider orders nitroglycerin tablets. Which should the nurse instruct the client to do?
Correct Answer: A
Rationale: Sublingual nitroglycerin is administered under the tongue for rapid absorption to relieve chest pain. Other methods (swallowing, chewing, or buccal placement) are incorrect for this medication.
Question 5 of 5
Which dietary restriction is critical in acute renal failure?
Correct Answer: A
Rationale: Low sodium prevents fluid retention and hypertension in acute renal failure.