NCLEX-RN
NCLEX RN Medical Surgical Practice Questions Questions
Extract:
Question 1 of 5
The nurse has assisted the physician at the bedside with insertion of a left subclavian, triple lumen catheter in a client admitted with lung cancer. Suddenly, the client becomes restless and tachypneic. The nurse should:
Correct Answer: A
Rationale: Restlessness and tachypnea post-catheter insertion suggest a pneumothorax, a complication. Assessing breath sounds detects absent or diminished sounds, guiding intervention. Removing the catheter, inserting an I.V., or repositioning does not address the urgent issue.
Question 2 of 5
After the initial phase of the burn injury, the client's plan of care will focus primarily on:
Correct Answer: C
Rationale: Infection prevention is critical in the acute phase of burn care, as burns compromise the skin's barrier, increasing infection risk. Other options are secondary priorities.
Question 3 of 5
A client's arterial blood gas values are as follows: pH, 7.31; PaO2, 80 mm Hg; PaCO2, 65 mm Hg; HCO3ˆ’, 36 mEq/L. The nurse should assess the client for?
Correct Answer: C
Rationale: The ABG shows uncompensated respiratory acidosis (low pH, high PaCO2) with adequate oxygenation (PaO2 80). Irritability is a symptom of CO2 retention. Cyanosis requires lower PaO2. Flushed skin and anxiety are less specific.
Question 4 of 5
The nurse should monitor the surgical client closely for which clinical manifestation with the administration of naloxone (Narcan)?
Correct Answer: A
Rationale: Naloxone can cause dizziness due to rapid reversal of opioid effects, leading to autonomic changes. This is a common side effect to monitor in surgical clients.
Question 5 of 5
A client with terminal cancer wishes to die at home. The nurse should:
Correct Answer: A
Rationale: Arranging home hospice services supports the client's wish to die at home, providing necessary care and support in a comfortable environment.