NCLEX-RN
NCLEX RN Med Surg Questions Questions
Extract:
Question 1 of 5
Which action is contraindicated for a client with a risk of increased ICP?
Correct Answer: C
Rationale: Coughing is contraindicated as it increases intracranial pressure.
Question 2 of 5
A client who has a history of Crohn's disease is admitted to the hospital with fever, diarrhea, cramping, abdominal pain, and weight loss. The nurse should monitor the client for:
Correct Answer: C
Rationale: Crohn's disease with diarrhea can lead to hypokalemia due to potassium loss in stool. Hyperalbuminemia and hypercalcemia are not typical, and thrombocytopenia is less directly related to these symptoms. CN: Physiological adaptation; CL: Analyze
Question 3 of 5
The client with a fractured tibia has been taking methocarbamol (Robaxin). Which of the following indicate that the drug is having the intended effect?
Correct Answer: C
Rationale: Methocarbamol is a muscle relaxant, effective when muscle spasms are relieved.
Question 4 of 5
A client with type 1 diabetes is admitted to the emergency department with dehydration following the flu. The client has a blood glucose level of 325 mg/dL and a serum potassium level of 3.5 mEq. The physician has ordered 1,000 mL 5% dextrose in water to be infused every 8 hours. Prior to implementing the physician orders, the nurse should contact the physician, explain the situation, provide background information, report the current assessment of the client, and:
Correct Answer: C
Rationale: 5% dextrose in water is inappropriate for a hyperglycemic client (325 mg/dL), as it may worsen hyperglycemia. The nurse should verify the order, likely suggesting normal saline instead.
Question 5 of 5
Which of the following respiratory patterns indicates increasing intracranial pressure in the brain stem?
Correct Answer: A
Rationale: Slow, irregular respirations (e.g., Cheyne-Stokes or ataxic breathing) are indicative of brain stem dysfunction due to increasing intracranial pressure. Rapid, shallow respirations may indicate hypoxia, asymmetric chest excursion suggests mechanical issues, and nasal flaring is associated with respiratory distress, not specifically ICP.