NCLEX RN Medical Surgical Questions and Answers
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Question 1 of 5.
The nurse is assessing a hospitalized older client for the presence of pressure ulcers. The nurse notes that the client has a 1" × 1" area on his sacrum in which there is skin breakdown as far as the dermis. What should the nurse note on the chart?
A. Stage I pressure ulcer.
B. Stage II pressure ulcer.
C. Stage III pressure ulcer.
D. Stage IV pressure ulcer.
Explanation: A Stage II pressure ulcer involves partial-thickness skin loss extending to the dermis, matching the description of the sacral breakdown.
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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