NCLEX-RN
Med Surg RN NCLEX Practice Questions Questions
Extract:
Question 1 of 5
The nurse is monitoring a client after an above-the-knee amputation and notes that blood has saturated through the client and the dressing. The nurse should immediately:
Correct Answer: C
Rationale: Blood saturating the dressing post-amputation suggests significant bleeding, a potential emergency. The nurse should immediately call the physician for evaluation and intervention. Applying a tourniquet is extreme and requires an order, assessing vital signs is secondary, and elevating with a pillow may not address the bleeding source.
Question 2 of 5
A 15-year-old client needs life-saving emergency surgery, but his relatives live an hour away from the hospital and cannot sign the consent form. What is the nurse's best response?
Correct Answer: B
Rationale: For life-saving emergency surgery in a minor, telephone consent from the family with a witness is acceptable to meet legal requirements while expediting care.
Question 3 of 5
A client with bladder cancer has lost an estimated 500 mL blood in the urine. The client's hemoglobin is 8.0 g/dL, and the physician orders a unit of packed blood cells. To administer the packed red blood cells, the nurse should:
Correct Answer: A
Rationale: Packed red blood cells should be administered via a 19G I.V. with normal saline using Y tubing to prevent hemolysis, which can occur with dextrose solutions.
Question 4 of 5
A client in the PACU after spinal anesthesia reports a severe headache when sitting up. The nurse suspects:
Correct Answer: B
Rationale: A severe headache worsened by sitting up after spinal anesthesia is characteristic of a post-dural puncture headache due to cerebrospinal fluid leakage. This requires prompt management, such as hydration or an epidural blood patch.
Question 5 of 5
A client has mitral stenosis and is a prospective valve recipient. The nurse is instructing the client about health maintenance prior to surgery. Inability to follow which of the following regimens would pose the greatest health hazard to this client at this time?
Correct Answer: A
Rationale: Medication therapy (e.g., anticoagulants, diuretics) is critical to manage symptoms and prevent complications like thromboembolism in mitral stenosis.