NCLEX-RN
NCLEX RN Medical Surgical Questions and Answers Questions
Extract:
Question 1 of 5
Which nursing intervention has been found to be the most effective means of preventing plantar flexion in a client who has had a stroke with residual paralysis?
Correct Answer: A
Rationale: A firm footboard maintains the foot in a neutral position, preventing plantar flexion contractures. Repositioning, shoes, or massage are less effective for this specific purpose.
Question 2 of 5
A client has been admitted to the coronary care unit. The nurse observes third-degree heart block at a rate of 35 bpm on the client's cardiac monitor. The client has a blood pressure of 90/60. The nurse should take which of the following actions first?
Correct Answer: A
Rationale: Third-degree heart block with a rate of 35 bpm and hypotension requires immediate transcutaneous pacing to restore adequate heart rate and perfusion.
Question 3 of 5
A 62-year-old Chinese man is admitted with multiple injuries from a motor vehicle accident. He complains of severe pain and requests frequent medication. One of the assistive nursing personnel expresses surprise, saying, "I thought Asian people were very stoic about pain." Which is the nurse's best response about pain?
Correct Answer: A
Rationale: Pain expression and perception vary individually due to cultural, personal, and situational factors, countering the stereotype. Pain tolerance and perception are not uniform or solely genetic.
Question 4 of 5
A client with impaired cardiac functioning is at risk during anesthesia induction with thiopental sodium (Sodium Pentothal) because this drug causes:
Correct Answer: C
Rationale: Thiopental can cause hypotension, which is particularly risky in clients with impaired cardiac function, as it may exacerbate cardiovascular instability during induction.
Question 5 of 5
The nurse in the emergency department is administering an order for 20 mg intravenous furosemide (Lasix) which is to be given immediately. The nurse seems the client's identification and the medication barcode. The medication administration system does not verify that furosemide is ordered for this client; however, the furosemide is prepared in the accurate unit dose for intravenous infusion. The nurse should do which of the following next?
Correct Answer: A
Rationale: A barcode verification failure indicates a potential error, requiring immediate pharmacist consultation to confirm the order and ensure patient safety.