NCLEX-RN
NCLEX RN Medical Surgical Questions and Answers Questions
Extract:
Question 1 of 5
The monitor technician informs the nurse that the client has started having premature ventricular contractions every other beat. Which is the priority nursing action?
Correct Answer: B
Rationale: PVCs every other beat (bigeminy) may indicate serious irritability. Assessing orientation and vital signs first determines the client's stability, guiding further actions.
Question 2 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 3 of 5
What is the nurse's best action for a client with a C6 spinal cord injury?
Correct Answer: A
Rationale: Assessing respiratory status is the priority due to potential diaphragmatic impairment in a C6 injury.
Question 4 of 5
A nurse has two clients that have an order to receive a blood transfusion of packed red blood cells at the same time. The first client's blood pressure dropped from the preoperative value of 120/80 mm Hg to a postoperative value of 100/50. The second client is 58 years old and is hospitalized because he developed dehydration and anemia following pneumonia. After checking the patency of their I.V. lines and vital signs, which should the nurse do next?
Correct Answer: C
Rationale: The first client's significant blood pressure drop (120/80 to 100/50) indicates potential hypovolemia or bleeding, making their transfusion a priority to restore volume and oxygen-carrying capacity. The second client's condition is less urgent. The nurse should call for and hang the first client's transfusion first.
Question 5 of 5
The nurse is assessing a client post-laminectomy for complications. Which finding requires immediate action?
Correct Answer: B
Rationale: Clear drainage may indicate a cerebrospinal fluid leak, a critical complication requiring urgent intervention.