NCLEX-RN
Med Surg RN NCLEX Practice Questions Questions
Extract:
Question 1 of 5
When assessing a client for early septic shock, the nurse observes for which of the following?
Correct Answer: B
Rationale: Early septic shock is characterized by vasodilation and increased cardiac output, leading to warm, flushed skin. Cool, clammy skin and decreased blood pressure occur in later stages, and hemorrhage is not a feature of septic shock.
Question 2 of 5
A 20-year-old who hit his head while playing football has a tonic-clonic seizure. Upon awakening from the seizure, the client asks the nurse, "What caused me to have a seizure? I've never had one before." Which cause should the nurse include in the response as a primary cause of tonic-clonic seizures in adults older than age 20?
Correct Answer: A
Rationale: Head trauma is a primary cause of seizures in adults over 20, especially in the context of a recent injury. Electrolyte imbalances, congenital defects, or epilepsy are less likely without additional history.
Question 3 of 5
A client with a hemorrhagic stroke is slightly agitated, heart rate is 118, respirations are 22, bilateral rhonchi are auscultated, SpO2 is 94%, blood pressure is 144/88, and oral secretions are noted. What order of interventions should the nurse follow when suctioning the client to prevent increased intracranial pressure (ICP) and maintain adequate cerebral perfusion?
Order the Items
Source Container
Correct Answer: B,D,A,C
Rationale: The correct order is: 1) Hyperoxygenate to prevent hypoxia (
B); 2) Provide sedation to reduce agitation and ICP spikes (
D); 3) Suction the airway to clear secretions (
A); 4) Suction the mouth to remove residual secretions (
C). This sequence minimizes ICP increases and ensures oxygenation.
Question 4 of 5
When assessing a client for early septic shock, the nurse observes for which of the following?
Correct Answer: B
Rationale: Early septic shock is characterized by vasodilation and increased cardiac output, leading to warm, flushed skin. Cool, clammy skin and decreased blood pressure occur in later stages, and hemorrhage is not a feature of septic shock.
Question 5 of 5
A client with peripheral vascular disease returns to the surgical care unit after having femoral-popliteal bypass grafting. Indicate in which order the nurse should conduct assessment of this client.
Order the Items
Source Container
Correct Answer: B,A,C,D
Rationale: The correct order is: 1) Peripheral pulses (to confirm graft patency and limb perfusion, the highest priority); 2) Postoperative pain (to assess comfort and detect complications); 3) Urine output (to monitor renal perfusion and fluid status); 4) Incision site (to check for infection or bleeding, less urgent). This prioritizes circulation and vital organ function.