NCLEX-RN
NCLEX RN Medical Surgical Practice Questions Questions
Extract:
Question 1 of 5
On the day of surgery, a client with diabetes who takes insulin on a sliding scale is ordered to have nothing by mouth and all medications withheld. The client's 6 a.m. glucose level is 300 mg/dL. The nurse should:
Correct Answer: C
Rationale: A glucose level of 300 mg/dL indicates significant hyperglycemia, which poses risks during surgery. Calling the physician for specific orders ensures appropriate insulin administration while adhering to NPO and surgical protocols.
Question 2 of 5
One goal of care for a client with PVD is to decrease anxiety, so as to decrease or prevent vasoconstriction of the:
Correct Answer: A
Rationale: Anxiety can trigger sympathetic nervous system activation, causing arterial vasoconstriction, which worsens ischemia in PVD. Reducing anxiety helps maintain arterial dilation and blood flow. Capillaries, lymphatics, and veins are less affected by this mechanism.
Question 3 of 5
The nurse is assessing a client who has a chest tube connected to a water-seal chest tube drainage system. According to the illustrationshown, which should the nurse do?
Correct Answer: D
Rationale:
To promote chest tube drainage the drainage system must be lower than the client's lungs. The amount of drainage is not abnormal; it is not necessary to notify the physician. The nurse should chart the amount and color of drainage every 4 to 8 hours.
Question 4 of 5
The nurse is to Ros instill drops of phenylephrine hydrochloride (Neo-Synephrine) into the client's eye prior to cataract surgery. Which of the following is the expected outcome?
Correct Answer: B
Rationale: Phenylephrine hydrochloride (Neo-Synephrine) is a sympathomimetic agent used to dilate the pupil (mydriasis) by stimulating the dilator muscle of the iris and to constrict blood vessels, reducing conjunctival redness and swelling before cataract surgery.
Question 5 of 5
The nurse monitors a client with cirrhosis for the development of hepatic encephalopathy. Which of the following would be an indication that hepatic encephalopathy is developing?
Correct Answer: A
Rationale: Hepatic encephalopathy causes decreased mental status (
A) due to ammonia buildup. Elevated blood pressure (
B), decreased urine output (
C), and labored respirations (
D) are not primary indicators.