NCLEX-RN
NCLEX RN Medical Surgical Practice Questions Questions
Extract:
Question 1 of 5
The nurse is obtaining a blood sample for a PTT test ordered for a client who is taking heparin. It is 5 a.m. When drawing the blood, the nurse should do which of the following? Select all that apply.
Correct Answer: B,C,E
Rationale: Rationales:
B) Checking the armband ensures correct client identification, critical for safety.
C) Labeling the vial in front of the client prevents errors. E) Asking the client to state their name confirms identity.
A) Awakening the client is unnecessary if asleep, as the draw can be done gently.
D) Room number is unreliable for identification.
Question 2 of 5
During the first 24 hours after thrombolytic treatment for an ischemic stroke, the primary goal is to control the client's:
Correct Answer: C
Rationale: Controlling blood pressure is the primary goal post-thrombolytic therapy to prevent hemorrhagic transformation. Pulse, respirations, and temperature are monitored but are secondary.
Question 3 of 5
Which intervention is appropriate for a client on hemodialysis?
Correct Answer: A
Rationale: Checking for a thrill ensures fistula patency for dialysis.
Question 4 of 5
After a total laryngectomy, the client has a feeding tube. The feeding tube is effective if the tube feedings:
Correct Answer: A
Rationale: The primary purpose of a feeding tube post-laryngectomy is to meet the client's fluid and nutritional needs, as oral intake may be impaired due to surgical changes.
Question 5 of 5
The nurse is to administer Polycillin (ampicillin) 500 mg orally to a client with a ruptured appendix. The nurse checks the capsule in the client's medication box which is located inside of the client's room. The dosage of the medication is not labeled, but the nurse recognizes the color and shape of the capsule. The nurse should next:
Correct Answer: C
Rationale: Contacting the pharmacy to bring a properly labeled medication ensures safe administration, as recognizing the capsule's color and shape is insufficient for verification. Administering without confirmation or relying on another nurse risks error, and reporting to the manager delays care. CN: Safety and infection control; CL: Synthesize