NCLEX-RN
Med Surg RN NCLEX Practice Questions Questions
Extract:
Question 1 of 5
Nursing assessment of a 54-year-old client in the emergency department reveals severe back pain, Grey Turner's sign, nausea, blood pressure of 90/40, heart rate 128 beats per minute and respirations 28 per minute. The nurse should first:
Correct Answer: B
Rationale: Severe back pain, Grey Turner's sign (flank bruising), and hemodynamic instability (hypotension, tachycardia, tachypnea) suggest a ruptured abdominal aortic aneurysm. Placing a large-bore I.V. first ensures access for fluids and blood transfusion to stabilize the client. Urine output, positioning, and nasogastric tube are secondary.
Question 2 of 5
The nurse should instruct the client with a platelet count of less than 150,000/µL to avoid which of the following activities?
Correct Answer: B
Rationale: A platelet count below 150,000/µL indicates thrombocytopenia, increasing bleeding risk. Valsalva's maneuver (e.g., straining during bowel movements) can raise intracranial pressure and cause bleeding, such as cerebral hemorrhage, and should be avoided. Ambulation, visiting children, and semi-Fowler's position are generally safe unless other conditions are present.
Question 3 of 5
A client is transferred to his room from the intensive care unit after a craniotomy for treatment of a malignant brain tumor in the occipital region. The nurse should question which of these orders?
Correct Answer: A
Rationale: Ibuprofen (an NSAI
D) should be questioned post-craniotomy due to the risk of bleeding, which can be exacerbated by its antiplatelet effects in the context of recent brain surgery.
Question 4 of 5
A client with cirrhosis begins to develop ascites. Spironolactone (Aldactone) is prescribed to treat the ascites. The nurse should monitor the client closely for which of the following drug-related adverse effects?
Correct Answer: B
Rationale: Spironolactone, a potassium-sparing diuretic, can cause hyperkalemia (
B), a critical adverse effect. Constipation (
A), irregular pulse (
C), and dysuria (
D) are not commonly associated.
Question 5 of 5
A client with cancer has diarrhea and a nursing diagnosis of Impaired skin integrity related to the frequent diarrhea. Which of the following nursing interventions is appropriate for this diagnosis?
Correct Answer: D
Rationale: Cleaning with unscented soap and water, rinsing, and patting dry after each bowel movement prevents skin breakdown and maintains integrity in clients with diarrhea.