NCLEX-RN
Medical Surgical Nursing NCLEX RN Questions Questions
Extract:
Question 1 of 5
Which of the following interventions should the nurse include in the client's plan of care to prevent complications associated with TPN administered through a central line?
Correct Answer: B,D
Rationale:
To prevent complications with TPN via a central line, taping all connections (
B) prevents dislodgement, and a moisture-proof dressing (
D) reduces infection risk. Clean technique (
A) is insufficient; sterile technique is required. Bed rest (
C) is not necessary and may increase complications like thrombosis. CN: Pharmacological and parenteral therapies; CL: Create
Question 2 of 5
For a client with rib fractures and a pneumothorax, the physician prescribes morphine sulfate, 1 to 2 mg/hour, given I.V. as needed for pain. The nursing care goal is to provide adequate pain control so that the client can breathe effectively. Which of the following outcomes would indicate successful achievement of this goal?
Correct Answer: A
Rationale: A pain rating of 0 indicates adequate pain control, enabling effective breathing. A respiratory rate of 26 is elevated, and a PaO2 of 70 mm Hg suggests mild hypoxemia, neither confirming pain control.
Question 3 of 5
The nurse teaches a client who had cystoscopy about the urge to void when the procedure is over. What other teaching should be included?
Correct Answer: D
Rationale: After cystoscopy, the client may feel an urge to void due to bladder irritation. Teaching to ring for assistance ensures safety, as ambulation may be unsteady post-procedure.
Question 4 of 5
When the nurse talks with a client with multiple sclerosis who has slurred speech, which nursing intervention is contraindicated?
Correct Answer: D
Rationale: Asking the client to speak louder when tired is contraindicated, as it may exacerbate fatigue and worsen speech. Encouraging slow speech, allowing time, and repeating words support communication.
Question 5 of 5
A 60-year-old male client comes into the emergency department with a complaint of crushing substernal chest pain that radiates to his shoulder and left arm. The admitting diagnosis is acute myocardial infarction (MI). Immediate admission orders include oxygen by nasal cannula at 4 L/minute, blood work, a chest radiograph, a 12-lead electrocardiogram (ECG), and 2 mg of morphine sulfate given I.V. The nurse should first:
Correct Answer: A
Rationale: Administering morphine first relieves pain, reducing myocardial oxygen demand and stabilizing the client. ECG and blood work follow to confirm diagnosis, but pain management is the priority.