Click to highlight the orders that the nurse should consider a priorit

NCLEX RN Questions Medical Surgical Nursing

Home / Nursing & Allied Health Certifications / NCLEX RN / RN Medical Surgical Nursing

Question 1 of 5.

Extract:The nurse in the emergency department (ED) is caring for a 62-year-old male client. Item 5 of 6 Triage Note 1700: â€¢ The client was brought to the ED after collapsing on a tennis court. â€¢ Vital signs: BP 94/57, T 105Â° F (40.5Â° C), P 115, RR 26, Pulse oximetry 95% on room air. â€¢ The client is lethargic and confused. Skin is pale, and there is some perspiration on the forehead. Thready peripheral pulses, clear lung fields bilaterally, tachypnea, shallow respirations.

Click to highlight the orders that the nurse should consider a priority.

A. Perform admission medication reconciliation and admit the client to the intensive care unit

B. Remove the client's clothing

C. Start a large-bore peripheral vascular access device

D. 0.9% sodium chloride (normal saline) 1000 mL, IV, once

E. Obtain medical records from the client's outpatient primary healthcare provider

F. Insert temperature-sensing indwelling urinary catheter

G. Apply a cooling blanket to the client

Explanation: Priority orders address immediate life-threatening issues: removing clothing (B), IV access (C), saline (D), temperature catheter (F), and cooling blanket (G) manage heat stroke and hypotension. Medication reconciliation (A) and medical records (E) are secondary.

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.

Related Questions

When instructing a client who has been newly diagnosed with vasospastic disorder (Raynaud's phenomenon) about management of care, the nurse should discuss which of the following topics?

A client is discharged after being hospitalized for thrombophlebitis. She will be driving home with her daughter, who lives 2 hours away. During the 2-hour ride, the nurse should advise the client to:

A client has an emergency embolectomy for an embolus in the femoral artery. After the client returns from the recovery room, in what order, from first to last, should the nurse provide care?

The nurse is planning care for a client who had surgery for abdominal aortic aneurysm repair 2 days ago. The pain medication and the use of relaxation and imagery techniques are not relieving the client's pain and the client refuses to get out of bed to ambulate as ordered. The nurse contacts the physician, explains the situation, and provides information about drug dose, frequency of administration, the client's vital signs, and the client's score on the pain scale. The physician tells the nurse that the current order for pain medication is sufficient and the client will be fine in a few days. The nurse should next:

A client was admitted to the hospital with iron deficiency anemia and blood-streaked emesis. Which question is most appropriate for the nurse to ask in determining the extent of the client's activity intolerance?