NCLEX RN Medical Surgical Questions
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Question 1 of 5.
A nurse is educating a student nurse about blood transfusions. Which of the following statements by the student nurse indicates the need for additional teaching? Select all that apply.
A. If a client should develop crackles in their lung fields, it is a sign of a hemolytic reaction.
B. Transfusion-related graft versus host disease most commonly occurs in immuno-suppressed individuals.
C. Transfusion-associated circulatory overload (TACO) is more common in clients with renal failure.
D. It is important to ask the client about history of previous blood transfusions.
E. Pre-medication with diphenhydramine and acetaminophen is always needed before transfusion.
Explanation: Crackles in the lung fields indicate transfusion-associated circulatory overload (TACO), not a hemolytic reaction, which typically presents with fever, chills, and hemoglobinuria. Pre-medication with diphenhydramine and acetaminophen is not always required, only when prescribed for clients with a history of allergic reactions. The other statements are correct: graft versus host disease is common in immunosuppressed clients, TACO is more likely in renal failure, and transfusion history is important.
Question 2 of 5.
The nurse notices that a client's heart rate decreases from 63 to 50 beats per minute on the monitor. The nurse should first:
A. Administer Atropine 0.5 mg I.V. push.
B. Auscultate for abnormal heart sounds.
C. Prepare for transcutaneous pacing.
D. Take the client's blood pressure.
Explanation: A heart rate of 50 bpm may indicate bradycardia. Taking the blood pressure first assesses hemodynamic stability, guiding whether immediate intervention (e.g., atropine or pacing) is needed.
Question 3 of 5.
The nurse is assessing clients at a health fair. Which client is at greatest risk for coronary artery disease?
A. A 32-year-old female with mitral valve prolapse who quit smoking 10 years ago.
B. A 43-year-old male with a family history of CAD and cholesterol level of 158.
C. A 56-year-old male with an HDL of 60 who takes atorvastatin (Lipitor).
D. A 65-year-old female who is obese with an LDL of 188.
Explanation: Obesity and elevated LDL (188) are significant risk factors for coronary artery disease. The other clients have lower-risk profiles due to younger age, smoking cessation, or controlled lipids.
Question 4 of 5.
The physician refers the client with unstable angina for a cardiac catheterization. The nurse explains to the client that this procedure is being used in this specific case to:
A. Open and dilate blocked coronary arteries.
B. Assess the extent of arterial blockage.
C. Bypass obstructed vessels.
D. Assess the functional adequacy of the valves and heart muscle.
Explanation: Cardiac catheterization in unstable angina assesses the extent of coronary artery blockage to guide interventions like angioplasty or bypass surgery.
Question 5 of 5.
The nurse finds the apical impulse below the fifth intercostal space. The nurse suspects:
A. Left atrial enlargement.
B. Left ventricular enlargement.
C. Right atrial enlargement.
D. Right ventricular enlargement.
Explanation: An apical impulse below the fifth intercostal space suggests left ventricular enlargement, common in heart failure due to ventricular dilation.
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