Medical Surgical NCLEX RN
Home / Nursing & Allied Health Certifications / NCLEX RN / RN Medical Surgical Nursing
Question 1 of 5.
The nurse is planning to give preoperative instructions to a client who will be undergoing rhinoplasty. Which of the following instructions should be included:
A. After surgery, nasal packing will be in place for 7 to 10 days.
B. Normal saline nose drops will need to be administered preoperatively.
C. The results of the surgery will be immediately obvious postoperatively.
D. Aspirin-containing medications should not be taken for 2 weeks before surgery.
Explanation: Aspirin can increase bleeding risk, so it should be avoided for 2 weeks before surgery. Nasal packing is typically removed within 1–3 days. Saline drops are not routinely required preoperatively. Surgical results may take weeks to months to be fully apparent due to swelling.
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.
Related Questions