NCLEX RN Medical Surgical Questions and Answers
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Question 1 of 5.
An older adult takes two 81 mg aspirin tablets daily to prevent a heart attack. The client reports having a constant 'ringing' in both ears. How should the nurse respond to the client's comment?
A. Tell the client that 'ringing' in the ears is associated with the aging process.
B. Refer the client to have a hearing test.
C. Schedule the client for audiometric testing.
D. Explain to the client that the 'ringing' may be related to the aspirin.
Explanation: Aspirin, even at low doses, can cause tinnitus (ringing in the ears) as a side effect. The nurse should explain this potential link and advise consulting the physician.
Question 2 of 5.
The nurse has completed an assessment on a client with a decreased cardiac output. Which findings should receive the highest priority?
A. BP 110/62, atrial fibrillation with HR 82, bibasilar crackles.
B. Confusion, urine output 15 mL over the last 2 hours, orthopnea.
C. SpO2 92 on 2 liters nasal cannula, respirations 20, 1+ edema of lower extremities.
D. Weight gain of 1 kg in 3 days, BP 130/80, mild dyspnea with exercise.
Explanation: Confusion, low urine output, and orthopnea indicate severe heart failure with potential cerebral and renal hypoperfusion, requiring immediate intervention. Other options reflect stable or less urgent findings.
Question 3 of 5.
Which of the following reflects the principle on which a client's diet will most likely be based during the acute phase of myocardial infarction?
A. Liquids as desired.
B. Small, easily digested meals.
C. Three regular meals per day.
D. Nothing by mouth.
Explanation: Small, easily digested meals reduce the metabolic demand on the heart and prevent gastrointestinal distress, which could exacerbate myocardial oxygen demand during the acute phase of MI.
Question 4 of 5.
Which of the following symptoms should the nurse teach the client with unstable angina to report immediately to her physician?
A. A change in the pattern of her pain.
B. Pain during sexual activity.
C. Pain during an argument with her husband.
D. Pain during or after an activity such as lawn-mowing.
Explanation: A change in the pattern of angina pain may indicate worsening ischemia or progression to unstable angina or MI, requiring immediate medical attention.
Question 5 of 5.
A client receiving a loop diuretic should be encouraged to eat which of the following foods? Select all that apply.
A. Angel food cake.
B. Banana.
C. Dried fruit.
D. Orange juice.
E. Peppers.
Explanation: Loop diuretics like furosemide cause potassium loss. Bananas (B), dried fruit (C), and orange juice (D) are potassium-rich, helping prevent hypokalemia.
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