NCLEX-RN
NCLEX RN Medical Surgical Questions and Answers Questions
Extract:
Question 1 of 5
The nurse is developing a plan to teach a client deep-breathing exercises to expand collapsed alveoli and prevent postoperative atelectasis and pneumonia. Which of the following steps should be included? Select all that apply.
Correct Answer: A,B,C,D
Rationale: Splinting the incision (
A), slow nasal inhalation with pursed-lip exhalation (
B), holding the breath (
C), and repeating 5-10 times hourly (
D) are correct steps for deep-breathing exercises to prevent atelectasis. Closing one nostril (E) is not part of this technique.
Question 2 of 5
To decrease intraocular pressure following cataract surgery, the nurse should instruct the client to avoid:
Correct Answer: B
Rationale: Coughing increases intraocular pressure by causing a Valsalva maneuver, which can strain the surgical site and lead to complications like hemorrhage or wound dehiscence.
Question 3 of 5
The American Heart Association (AHA) guidelines urge greater availability of automated external defibrillators (AEDs) and people trained to use them. AEDs are used in cardiac arrest situations for:
Correct Answer: C
Rationale: AEDs are used for early defibrillation in ventricular fibrillation or pulseless ventricular tachycardia, as these are shockable rhythms that can be corrected to restore cardiac function.
Question 4 of 5
A client has been admitted to the coronary care unit. The nurse observes third-degree heart block at a rate of 35 bpm on the client's cardiac monitor. The client has a blood pressure of 90/60. The nurse should take which of the following actions first?
Correct Answer: A
Rationale: Third-degree heart block with a rate of 35 bpm and hypotension requires immediate transcutaneous pacing to restore adequate heart rate and perfusion.
Question 5 of 5
When developing a teaching plan for a client who is prescribed acetaminophen (Tylenol) for muscle pain, which information should the nurse expect to include? Select all that apply.
Correct Answer: A,B,C
Rationale: Acetaminophen is safe for aspirin allergies, does not affect platelets, and causes minimal gastric distress. It has weak anti-inflammatory effects and does not require INR monitoring.