Questions 108

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Med Surg RN NCLEX Practice Questions Questions

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Question 1 of 5

Which of the following describes decerebrate posturing?

Correct Answer: D

Rationale: Decerebrate posturing involves rigid extension of all extremities with arched back, indicating severe brain stem dysfunction. The other options describe decorticate posturing or incorrect combinations of movements.

Question 2 of 5

Nursing assessment of a 54-year-old client in the emergency department reveals severe back pain, Grey Turner's sign, nausea, blood pressure of 90/40, heart rate 128 beats per minute and respirations 28 per minute. The nurse should first:

Correct Answer: B

Rationale: Severe back pain, Grey Turner's sign (flank bruising), and hemodynamic instability (hypotension, tachycardia, tachypnea) suggest a ruptured abdominal aortic aneurysm. Placing a large-bore I.V. first ensures access for fluids and blood transfusion to stabilize the client. Urine output, positioning, and nasogastric tube are secondary.

Question 3 of 5

Which intervention is appropriate for a client on hemodialysis?

Correct Answer: A

Rationale: Checking for a thrill ensures fistula patency for dialysis.

Question 4 of 5

When teaching a client newly diagnosed with primary Addison's disease, the nurse should explain that the disease results from:

Correct Answer: C

Rationale: Primary Addison's disease is caused by idiopathic adrenal gland atrophy, leading to deficient cortisol and aldosterone production.

Question 5 of 5

A client with cirrhosis begins to develop ascites. Spironolactone (Aldactone) is prescribed to treat the ascites. The nurse should monitor the client closely for which of the following drug-related adverse effects?

Correct Answer: B

Rationale: Spironolactone, a potassium-sparing diuretic, can cause hyperkalemia (
B), a critical adverse effect. Constipation (
A), irregular pulse (
C), and dysuria (
D) are not commonly associated.

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A client is admitted to the emergency department with a full thickness burn to his right arm. Upon assessment, the arm is edema, the agent is mottled, and radial pulse is now absent. The client states that the pain is 8 on a scale of 1 to 10 . The nurse should:
A client with cirrhosis is receiving Lactulose (Cephulac). During the assessment the nurse notes increased confusion and asterixis. The nurse should:
Which dietary restriction is critical in acute renal failure?

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