NCLEX-RN
NCLEX RN Medical Surgical Questions Questions
Extract:
Question 1 of 5
The nurse is reviewing a client's chart and notes a discrepancy in the TPN order. Which action should the nurse take first?
Correct Answer: B
Rationale: Contacting the prescribing physician for clarification is the first action to resolve a discrepancy in a TPN order, ensuring safety and accuracy. Adjusting the rate, continuing the current rate, or documenting without clarification risks errors. CN: Safety and infection control; CL: Synthesize
Question 2 of 5
A client refuses to remove a religious necklace before surgery despite hospital policy. The nurse's best response is:
Correct Answer: B
Rationale: Taping the necklace securely respects the client's beliefs while ensuring safety by preventing the item from interfering with the surgical field.
Question 3 of 5
A client wakes up in the postanesthesia care unit and sees a drain with bright red fluid in it exiting from her total hip incision. She asks the nurse, 'Is this supposed to be there?' Which of the following represents the nurse's best response?
Correct Answer: A
Rationale: Explaining that the drain removes blood and fluid for healing reassures the client and accurately describes the purpose of the drain in a total hip incision.
Question 4 of 5
A client who has been taking carisoprodol (Soma) at home for a fractured arm is admitted with a blood pressure of 80/50 mm Hg, a pulse rate of 115 bpm, and respirations of 8 breaths/minute and shallow. The nurse interprets these findings as indicating which of the following?
Correct Answer: B
Rationale: These vital signs suggest a hypersensitivity reaction, a serious adverse effect of carisoprodol.
Question 5 of 5
The nurse is assessing a client who is in the early stages of cirrhosis of the liver. Which focused assessment is appropriate?
Correct Answer: D
Rationale: Jaundice (
D) is a common early sign of cirrhosis due to impaired bilirubin metabolism. Peripheral edema (
A) and ascites (
B) occur later. Anorexia (
C) is less specific.