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Free NCLEX RN Questions for Med Surg Questions

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Question 1 of 5

What is a priority nursing assessment in the first 24 hours after admission of the client with a thrombotic stroke?

Correct Answer: B

Rationale: Pupil size and pupillary response are priority assessments to detect neurological deterioration, such as increased ICP or stroke extension. Cholesterol, bowel sounds, and echocardiograms are not immediate priorities.

Question 2 of 5

While caring for a client who has sustained a myocardial infarction (MI), the nurse notes eight premature ventricular contractions (PVCs) in 1 minute on the cardiac monitor. The client is receiving an I.V. infusion of 5% dextrose in water (D5W) and oxygen at 2 L/minute. The nurse's first course of action should be:

Correct Answer: B

Rationale: Frequent PVCs (eight per minute) may indicate irritability of the myocardium, risking serious arrhythmias. Notifying the physician promptly ensures timely intervention, such as antiarrhythmic therapy.

Question 3 of 5

A client receives a thrombolytic agent. The expected outcome of this drug therapy includes:

Correct Answer: C

Rationale: Thrombolytic agents (e.g., alteplase) dissolve existing clots, such as emboli in pulmonary embolism or arterial occlusion, restoring blood flow. They do not improve cerebral perfusion, decrease vascular permeability, or prevent cerebral hemorrhage (they increase bleeding risk).

Question 4 of 5

A client who had a total hip replacement 2 days ago has developed an infection with a fever. The nursing diagnosis of fluid volume deficit related to diaphoresis is made. Which of the following is the most appropriate outcome?

Correct Answer: A

Rationale: Drinking 2,000 mL of fluid daily addresses fluid volume deficit due to diaphoresis.

Question 5 of 5

Which of the following should the nurse provide as part of the information to prepare the client for tonometry?

Correct Answer: B

Rationale:
Tonometry measures intraocular pressure and is typically painless with no adverse effects, requiring no pupil dilation or pain medication.

Similar Questions

A client with pneumonia has a temperature of 102.6°F (39.2°C), is diaphoretic, and has a productive cough. The nurse should include which of the following measures in the plan of care?
A client is brought to the emergency department unconscious. An empty bottle of aspirin was found in his car, and a drug overdose is suspected. Which of the following medications should the nurse have available for further emergency treatment?
A nurse is assessing a client with heart failure. The nurse should assess the client based on which compensatory mechanisms that are activated in the presence of heart failure? Select all that apply.
After stabilization of Addison's disease, the nurse teaches the client about stress management. The nurse should instruct the client to:
A client's serum ammonia level is elevated, and the physician orders 30 mL of lactulose (Cephulac). Which of the following is an adverse effect of this drug?

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