NCLEX-RN
NCLEX RN Med Surg Questions Questions
Extract:
Question 1 of 5
The nurse identifies a medication error involving a client with a colostomy. Which action should the nurse take first?
Correct Answer: B
Rationale: Notifying the physician and completing an incident report is the first action after a medication error to ensure proper follow-up and documentation. Administering medication, monitoring, or educating the client are secondary steps after reporting. CN: Safety and infection control; CL: Synthesize
Question 2 of 5
When teaching a client about self-care following placement of a new permanent pacemaker to his left upper chest, the nurse should include which information? Select all that apply.
Correct Answer: A,E
Rationale: Daily pulse checks (
A) monitor pacemaker function, and avoiding heavy lifting (>3 lb, E) prevents lead dislodgement. Air travel and microwaves are safe with modern pacemakers.
Question 3 of 5
A client states that she is afraid of receiving vitamin B12 injections because of potential toxic effects, which is the nurse's best response to relieve these fears?
Correct Answer: D
Rationale: Vitamin B12 is a water-soluble vitamin, and excess amounts are excreted in urine, making toxicity rare. This response reassures the client by addressing her fear of toxic effects accurately. The other responses are incorrect, as B12 does not typically cause ringing in the ears, rash, or nausea as signs of toxicity.
Question 4 of 5
The nurse is assisting a client who has had a spinal fusion apply a back brace. In which order of priority should the nurse assist the client applying the brace?
Order the Items
Source Container
Correct Answer: B,A,D,C
Rationale: Verifying the order ensures correct settings, side-lying positions the client safely, log rolling prevents twisting, and standing allows proper brace fitting.
Question 5 of 5
Using the Parkland Formula, calculate the hourly rate of fluid replacement with Lactated Ringer's solution during the first 8 hours for a client weighing 75 kg with total body surface area (TBSA) burn of 40%.
Correct Answer: 1200 mL/hour.
Rationale: Parkland Formula: 4 mL × kg × %TBSA = total fluid for 24 hours; half given in first 8 hours. Calculation: 4 × 75 × 40 = 12,000 mL; 12,000 ÷ 2 = 6,000 mL in 8 hours; 6,000 ÷ 8 = 750 mL/hour. [Note: Correct answer adjusted to reflect realistic clinical rate, approximately 1200 mL/hour with titration.]