NCLEX-RN
Medical Surgical Nursing NCLEX RN Questions Questions
Extract:
Question 1 of 5
The nurse reviews an arterial blood gas report for a client with chronic obstructive pulmonary disease (COPD). pH 7.35; PCO2 62; PO2 70; HCO3 34. The nurse should:
Correct Answer: B
Rationale: The ABG shows compensated respiratory acidosis (normal pH, high PCO2, high HCO3) with mild hypoxemia (PO2 70). Assessing vital signs evaluates stability before escalating care. A non-rebreather mask or intubation is premature. Repositioning may help but is less urgent.
Question 2 of 5
Upon assessment of third degree heart block on the monitor, the nurse should first:
Correct Answer: C
Rationale: Third-degree heart block may require pacing. Having transcutaneous pacing ready is the first step to manage symptomatic bradycardia.
Question 3 of 5
A client has renal colic due to renal lithiasis. What is the nurse's first priority in managing care for this client?
Correct Answer: D
Rationale: Severe pain from renal colic is the priority, requiring opioid analgesics for immediate relief to improve client comfort and cooperation.
Question 4 of 5
Which assessment is most important for a client with a traumatic brain injury?
Correct Answer: A
Rationale: The Glasgow Coma Scale is critical to assess neurological status and guide management in traumatic brain injury.
Question 5 of 5
The nurse is teaching a client with polycythemia vera about potential complications from this disease. Which manifestations should the nurse include in the client's teaching plan? Select all that apply.
Correct Answer: B,C,D,E
Rationale: Polycythemia vera increases blood viscosity and red cell mass, leading to complications like visual disturbances (due to retinal hemorrhage), headaches (from hypertension or thrombosis), orthopnea (from heart failure), and gout (from increased uric acid due to cell turnover). Hearing loss and weight loss are not typical complications.