NCLEX-RN
NCLEX RN Medical Surgical Questions and Answers Questions
Extract:
Question 1 of 5
The nurse sees a client walking in the hallway who begins to have a seizure. The nurse should do which of the following in priority order?
Correct Answer: C,A,B,D
Rationale: The priority order is: 1) Ease the client to the floor to prevent injury (
C); 2) Maintain a patent airway to ensure oxygenation (
A); 3) Record seizure activity for accurate reporting (
B); 4) Obtain vital signs post-seizure to assess stability (
D).
Question 2 of 5
A nurse has two clients that have an order to receive a blood transfusion of packed red blood cells at the same time. The first client's blood pressure dropped from the preoperative value of 120/80 mm Hg to a postoperative value of 100/50. The second client is 58 years old and is hospitalized because he developed dehydration and anemia following pneumonia. After checking the patency of their I.V. lines and vital signs, which should the nurse do next?
Correct Answer: C
Rationale: The first client's significant blood pressure drop (120/80 to 100/50) indicates potential hypovolemia or bleeding, making their transfusion a priority to restore volume and oxygen-carrying capacity. The second client's condition is less urgent. The nurse should call for and hang the first client's transfusion first.
Question 3 of 5
The best indicator that the client has learned how to give an insulin self-injection correctly is when the client can:
Correct Answer: A
Rationale: The ability to perform the insulin injection safely and correctly demonstrates mastery of the skill, which is the best indicator of learning.
Question 4 of 5
The nurse is preparing a client for a paracentesis. The nurse should:
Correct Answer: A
Rationale: Voiding before paracentesis (
A) prevents bladder injury. Side-lying (
B) is incorrect; upright is preferred. IV sedatives (
C) are not routine, and NPO (
D) is unnecessary.
Question 5 of 5
A client on peritoneal dialysis reports cloudy effluent. The nurse should:
Correct Answer: B
Rationale: Cloudy effluent suggests peritonitis, requiring immediate medical attention.