Med Surg RN NCLEX Practice Questions
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Question 1 of 5.
The nurse is documenting care of a client who is restrained in bed with bilateral wrist restraints. Following assessment of the restraints, the nurse's documentation should include which of the following? Select all that apply.
A. Nutrition and hydration needs.
B. Circulation and skin integrity.
C. Range of motion and positioning.
D. Behavioral responses and mental status.
Explanation: Documentation must include nutrition/hydration, circulation/skin integrity, range of motion/positioning, and behavioral/mental status to ensure safety and compliance.
Question 2 of 5.
A client with acute chest pain is receiving I.V. morphine sulfate. Which of the following results are intended effects of morphine in this client? Select all that apply.
A. Reduces myocardial oxygen consumption.
B. Promotes reduction in respiratory rate.
C. Prevents ventricular remodeling.
D. Reduces blood pressure and heart rate.
E. Reduces anxiety and fear.
Explanation: Morphine reduces pain, which lowers myocardial oxygen demand (A), decreases blood pressure and heart rate through vasodilation and reduced sympathetic response (D), and alleviates anxiety and fear (E). It does not prevent ventricular remodeling or directly reduce respiratory rate in this context.
Question 3 of 5.
Which of the following is an expected outcome for a client on the second day of hospitalization after a myocardial infarction (MI)? The client:
A. Has severe chest pain.
B. Can identify risk factors for MI.
C. Agrees to participate in a cardiac rehabilitation walking program.
D. Can perform personal self-care activities without pain.
Explanation: By the second day post-MI, the client should be able to perform self-care activities without pain, indicating stabilization. Severe pain is not expected, and risk factor identification or rehabilitation planning may occur later.
Question 4 of 5.
An older, sedentary adult may not respond to emotional or physical stress as well as a younger individual because of:
A. Left ventricular atrophy.
B. Irregular heartbeats.
C. Peripheral vascular occlusion.
D. Pacemaker placement.
Explanation: Aging leads to left ventricular atrophy, reducing cardiac reserve and impairing the heart's ability to respond to stress, unlike irregular heartbeats or pacemakers.
Question 5 of 5.
The nurse should teach the client that signs of digoxin toxicity include which of the following?
A. Rash over the chest and back.
B. Increased appetite.
C. Visual disturbances such as seeing yellow spots.
D. Elevated blood pressure.
Explanation: Visual disturbances, like seeing yellow spots (xanthopsia), are a hallmark of digoxin toxicity, requiring prompt reporting.
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