Questions 108

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NCLEX RN Questions Medical Surgical Nursing Questions

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Question 1 of 5

The nurse assesses vital signs on a client who has had epidural anesthesia. For which of the following should the nurse assess next?

Correct Answer: A

Rationale: Epidural anesthesia can cause urinary retention due to sensory and motor nerve blockade. Assessing for bladder distention is critical to prevent complications like bladder overdistension.

Question 2 of 5

A confused client with carbon monoxide poisoning experiences dizziness when ambulating to the bathroom. The nurse should:

Correct Answer: D

Rationale: Regular checks ensure safety and assist with bathroom needs, addressing dizziness and confusion. Side rails and restraints risk injury or agitation. Relying on a roommate is unreliable.

Question 3 of 5

A client has chest pain rated at 8 on a 10 point visual analog scale. The 12-lead electrocardiogram reveals ST elevation in the inferior leads and Troponin levels are elevated. What is the highest priority for nursing management of this client at this time?

Correct Answer: D

Rationale: The client is experiencing an acute myocardial infarction, indicated by ST elevation and elevated troponin. Reducing pain and myocardial oxygen demand is critical to minimize further cardiac damage.

Question 4 of 5

For which of the following preoperative clients should the nurse assess the glucose level? Select all that apply.

Correct Answer: A,B,C,D

Rationale: Clients at risk for hyperglycemia include those with diabetes (
A), high stress response (B, due to cortisol release), recent corticosteroid use (C, which raises glucose), and those receiving dextrose-containing IV fluids with a family history of diabetes (
D). A high carbohydrate diet alone (E) is less likely to warrant immediate glucose monitoring.

Question 5 of 5

The client's serum potassium level is elevated in acute renal failure, and the nurse administers sodium polystyrene sulfonate (Kayexalate). This drug acts to:

Correct Answer: D

Rationale: Kayexalate exchanges sodium for potassium in the colon, reducing serum potassium levels in acute renal failure.

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