Medical Surgical NCLEX RN
Home / Nursing & Allied Health Certifications / NCLEX RN / RN Medical Surgical Nursing
Question 1 of 5.
The nurse finds the client who has had an ileostomy crying. The client explains to the nurse, 'I'm upset because I know I won't be able to have children now that I have an ileostomy.' Which of the following would be the best response for the nurse?
A. Many women with an ileostomy can still have children; let's discuss your concerns with your doctor.
B. Having an ileostomy does prevent pregnancy, but you can explore adoption.
C. This is a common feeling; would you like to talk more about it?
D. I'll RAW arrange for a counselor to discuss your fertility options.
Explanation: The nurse should reassure the client that many women with ileostomies can still have children and offer to discuss this with the doctor, addressing the misconception directly. The other options either reinforce the misconception, avoid the concern, or defer without providing immediate support. CN: Psychosocial adaptation; CL: Synthesize
Question 2 of 5.
A client is admitted with a myocardial infarction and new onset atrial fibrillation. While auscultating the heart, the nurse notes an irregular heart rate and hears an extra heart sound at the apex after the S2 that remains constant throughout the respiratory cycle. The nurse should document these findings as:
A. Heart rate irregular with S3.
B. Heart rate irregular with S4.
C. Heart rate irregular with aortic regurgitation.
D. Heart rate irregular with mitral stenosis.
Explanation: An extra heart sound after S2 at the apex, constant through the respiratory cycle, is an S3, often associated with heart failure post-myocardial infarction. Atrial fibrillation causes an irregular heart rate.
Question 3 of 5.
A 58-year-old female with a family history of CAD is being seen for the annual physical examination. Fasting lab test results include: Total cholesterol 198; LDL cholesterol 120; HDL cholesterol 58; Triglycerides 148; Blood sugar 102; and C-reactive protein (CRP) 4.2. The health care provider informs the client that she will be started on a statin medication and aspirin. The client asks the nurse why she needs to take these medications. Which is the best response by the nurse?
A. The labs indicate severe hyperlipidemia and the medications will lower your LDL, along with a low-fat diet.'
B. The triglycerides are elevated and will be lowered to normal with these medications.'
C. The CRP is elevated indicating inflammation seen in cardiovascular disease, which can be lowered by the medications ordered.'
D. The medications are not indicated since your lab values are all normal.'
Explanation: Elevated CRP (4.2) indicates inflammation associated with cardiovascular risk. Statins and aspirin reduce inflammation and prevent cardiovascular events, addressing the client's risk profile.
Question 4 of 5.
The client is scheduled for a percutaneous transluminal coronary angioplasty (PTCA) to treat angina. Priority goals for the client immediately after PTCA should include:
A. Minimizing dyspnea.
B. Maintaining adequate blood pressure control.
C. Decreasing myocardial contractility.
D. Preventing fluid volume deficit.
Explanation: Maintaining adequate blood pressure post-PTCA ensures coronary perfusion and prevents complications like stent thrombosis or ischemia.
Question 5 of 5.
The nurse is admitting a 68-year-old male to the medical floor. The echocardiogram report revealed left ventricular enlargement. The nurse notes 2+ pitting edema in the ankles when getting the client into bed. Based on this finding, what should the nurse do first?
A. Assess respiratory status.
B. Draw blood for laboratory studies.
C. Insert a Foley catheter.
D. Weigh the client.
Explanation: Edema and left ventricular enlargement suggest heart failure, which can cause pulmonary edema. Assessing respiratory status first detects signs of respiratory distress.