NCLEX-RN
NCLEX RN Med Surg Questions Questions
Extract:
Question 1 of 5
The nurse is assessing an older Caucasian male who has a history of peripheral vascular disease. The nurse observes that the man's left great toe is black. The discoloration is probably a result of:
Correct Answer: C
Rationale: A black great toe in a client with PVD likely indicates gangrene, resulting from tissue necrosis due to severe ischemia from arterial occlusion. Atrophy causes muscle wasting, contraction is not a relevant term, and rubor refers to reddish discoloration, not black.
Question 2 of 5
One goal in caring for a client with arterial occlusive disease is to promote vasodilation in the affected extremity. To achieve this goal, the nurse encourages the client to:
Correct Answer: C
Rationale: Stopping smoking promotes vasodilation by reducing nicotine-induced vasoconstriction and improving endothelial function, critical in arterial occlusive disease. Applying heat risks burns in ischemic tissue, elevating legs worsens arterial flow, and jogging may be contraindicated due to claudication.
Question 3 of 5
During an initial assessment of a client diagnosed with vasospastic disorder (Raynaud's phenomenon), the nurse notes a sudden color change to white in the fingers. The nurse should first assess:
Correct Answer: B
Rationale: A sudden color change to white in Raynaud's indicates vasospasm. Assessing the radial pulse first confirms whether blood flow is present despite the vasospasm, guiding further action. Cyanosis, SpO2, and blood pressure are secondary, as pulse assessment is more immediate and specific.
Question 4 of 5
A client is receiving an I.V. infusion of 5% dextrose in water (D5W). The skin around the I.V. insertion site is red, warm to touch, and painful. The nurse should first:
Correct Answer: C
Rationale: Redness, warmth, and pain at the I.V. site indicate phlebitis or infiltration. The first action is to discontinue the I.V. to prevent further tissue damage. Changing fluids, applying a compress, or giving acetaminophen does not address the immediate issue.
Question 5 of 5
A client is admitted to the emergency department complaining of severe abdominal pain. A radiograph reveals a large abdominal aortic aneurysm. The primary goal at this time is to:
Correct Answer: C
Rationale: A large abdominal aortic aneurysm with severe pain suggests impending rupture, requiring emergency surgery to prevent catastrophic bleeding. Preparing the client for surgery is the primary goal, as it addresses the life-threatening condition. Circulation, pain, and breathing exercises are managed perioperatively.