NCLEX-RN
NCLEX RN Medical Surgical Questions and Answers Questions
Extract:
Question 1 of 5
The nurse is planning care for a client who is diagnosed with peripheral vascular disease (PVD) and has a history of heart failure. The nurse should develop a plan of care that is based on the fact that the client may have a low tolerance for exercise related to:
Correct Answer: A
Rationale: In PVD, decreased blood flow to the extremities limits oxygen delivery to muscles, reducing exercise tolerance. In heart failure, reduced cardiac output further exacerbates this limitation, as the heart cannot meet increased oxygen demands during activity. Increased blood flow or viscosity is not relevant, and the options are repeated incorrectly in the document.
Question 2 of 5
Which of the following nursing interventions would most likely promote self-care behaviors in the client with a hiatal hernia?
Correct Answer: C
Rationale: Encouraging the client to identify past instances of responsibility promotes self-efficacy and motivates self-care behaviors, which is most effective for long-term management.
Question 3 of 5
A client with acute respiratory distress syndrome (ARDS) is on a ventilator. The client's peak inspiratory pressures and spontaneous respiratory rate are increasing, and the PO2 is not improving. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse calls the physician with the recommendation for:
Correct Answer: A
Rationale: Increasing peak pressures, respiratory rate, and poor PO2 suggest agitation or asynchrony; I.V. sedation improves ventilator synchrony. Diet and pain medication are irrelevant. Increasing ventilator rate may worsen lung injury.
Question 4 of 5
A client has an amylase level of 450 units/L and lipase level of 659 units/L. The client has mid-epigastric pain with nausea. What assessment helps the nurse to determine severity of the client's condition?
Correct Answer: A
Rationale: Ranson's criteria (
A) assess pancreatitis severity using clinical and lab parameters like age, glucose, and white blood cell count. Vital signs (
B) and urine output (
C) are general but less specific. Glasgow Coma Scale (
D) is for neurological assessment, not pancreatitis severity.
Question 5 of 5
A client is to have a Schilling test. The nurse should:
Correct Answer: B
Rationale: The Schilling test assesses vitamin B12 absorption by measuring urinary excretion of radiolabeled B12. The nurse should start a 24- to 48-hour urine collection to capture the excreted B12. Methylcellulose, NPO status, and stool collection are not part of the Schilling test protocol.