NCLEX RN Questions Medical Surgical Nursing
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Question 1 of 5.
A client who underwent a lobectomy and has a water-seal chest drainage system is breathing with a little more effort and at a faster rate than 1 hour ago. The client's pulse rate is also increased. The nurse should:
A. Check the tubing to ensure that the client is not lying on it or kinking it.
B. Increase the suction.
C. Lower the drainage bottles 2 to 3 feet below the level of the client's chest.
D. Ensure that the chest tube has two clamps on it to prevent air leaks.
Explanation: Increased respiratory effort, rate, and pulse suggest a possible obstruction; checking for kinked or compressed tubing is the first step. Increasing suction, lowering bottles, or clamping tubes risks worsening the issue.
Question 2 of 5.
A client has chest pain rated at 8 on a 10 point visual analog scale. The 12-lead electrocardiogram reveals ST elevation in the inferior leads and Troponin levels are elevated. What is the highest priority for nursing management of this client at this time?
A. Monitor daily weights and urine output.
B. Permit unrestricted visitation by family and friends.
C. Provide client education on medications and diet.
D. Reduce pain and myocardial oxygen demand.
Explanation: The client is experiencing an acute myocardial infarction, indicated by ST elevation and elevated troponin. Reducing pain and myocardial oxygen demand is critical to minimize further cardiac damage.
Question 3 of 5.
When teaching the client with myocardial infarction (MI), the nurse explains that the pain associated with MI is caused by:
A. Left ventricular overload.
B. Impending circulatory collapse.
C. Extracellular electrolyte imbalances.
D. Insufficient oxygen reaching the heart muscle.
Explanation: MI pain results from myocardial ischemia due to insufficient oxygen delivery to the heart muscle, caused by coronary artery occlusion.
Question 4 of 5.
Crackles heard on lung auscultation indicate which of the following?
A. Cyanosis.
B. Bronchospasm.
C. Airway narrowing.
D. Fluid-filled alveoli.
Explanation: Crackles indicate fluid in the alveoli, often due to pulmonary edema in heart failure or post-MI, reflecting left ventricular dysfunction.
Question 5 of 5.
A client with chronic heart failure has atrial fibrillation and a left ventricular ejection fraction of 15%. The client is taking warfarin (Coumadin). The expected outcome of this drug is to:
A. Decrease circulatory overload.
B. Improve the myocardial workload.
C. Prevent thrombus formation.
D. Regulate cardiac rhythm.
Explanation: Warfarin prevents thrombus formation, critical in atrial fibrillation and low ejection fraction, which increase clot risk due to stasis.
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