Med Surg RN NCLEX Questions
Home / Nursing & Allied Health Certifications / NCLEX RN / RN Medical Surgical Nursing
Question 1 of 5.
A client with a hemorrhagic stroke is slightly agitated, heart rate is 118, respirations are 22, bilateral rhonchi are auscultated, SpO2 is 94%, blood pressure is 144/88, and oral secretions are noted. What order of interventions should the nurse follow when suctioning the client to prevent increased intracranial pressure (ICP) and maintain adequate cerebral perfusion?
- A. Suction the airway.
- B. Hyperoxygenate.
- C. Suction the mouth.
- D. Provide sedation.
- B. Hyperoxygenate.
- D. Provide sedation.
- A. Suction the airway.
- C. Suction the mouth.
Correct arrangement
Explanation: The correct order is: 1) Hyperoxygenate to prevent hypoxia (B); 2) Provide sedation to reduce agitation and ICP spikes (D); 3) Suction the airway to clear secretions (A); 4) Suction the mouth to remove residual secretions (C). This sequence minimizes ICP increases and ensures oxygenation.
Question 2 of 5.
A client receives fibrinolytic therapy upon admission following a myocardial infarction. He is now receiving an I.V. infusion of heparin sodium at 1,200 units/hour. The dilution is 25,000 units/500 mL. How many milliliters per hour will this client receive?
Answer: 24 mL/hour
Explanation: To calculate: (1,200 units/hour ÷ 25,000 units) × 500 mL = 24 mL/hour. This is a calculation question, not multiple-choice, so no choices or correct answer letter is provided.
Question 3 of 5.
Which of the following is an expected outcome when a client is receiving an I.V. administration of furosemide?
A. Increased blood pressure.
B. Increased urine output.
C. Decreased pain.
D. Decreased premature ventricular contractions.
Explanation: Furosemide, a loop diuretic, promotes diuresis, increasing urine output to reduce fluid overload in conditions like heart failure or post-MI.
Question 4 of 5.
During the previous few months, a 56-year-old woman felt brief twinges of chest pain while working in her garden and has had frequent episodes of indigestion. She comes to the hospital after experiencing severe anterior chest pain while raking leaves. Her evaluation confirms a diagnosis of stable angina pectoris. After stabilization and treatment, the client is discharged from the hospital. At her follow-up appointment, she is discouraged because she is experiencing pain with increasing frequency. She states that she visits an invalid friend twice a week and now cannot walk up the second flight of steps to the friend's apartment without pain. Which of the following measures that the nurse could suggest would most likely help the client prevent this problem?
A. Visit her friend early in the day.
B. Rest for at least an hour before climbing the stairs.
C. Take a nitroglycerin tablet before climbing the stairs.
D. Lie down once she reaches the friend's apartment.
Explanation: Taking sublingual nitroglycerin before exertion (e.g., climbing stairs) prevents angina by dilating coronary arteries, increasing myocardial oxygen supply.
Question 5 of 5.
The nurse should be especially alert for signs and symptoms of digoxin toxicity if serum levels indicate that the client has a:
A. Low sodium level.
B. High glucose level.
C. High calcium level.
D. Low potassium level.
Explanation: Low potassium (hypokalemia) increases the risk of digoxin toxicity by enhancing digoxin's binding to cardiac cells, leading to arrhythmias.
Related Questions