Medical Surgical Nursing NCLEX RN Questions
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Question 1 of 5.
The nurse is preparing to administer an intramuscular (IM) injection into the client's vastus lateralis. The nurse is correct in identifying the landmark by
A. palpating to find greater trochanter and knee joints; divide the vertical distance between these two landmarks into thirds; inject into the middle third.
B. locating the acromion process; inject only into the upper third of muscle that begins about two fingerbreadths below the acromion.
C. locating the greater trochanter, iliac tubercle, and iliac crest; places palm over the greater trochanter, over iliac tubercle, along the ileum; inject into center of V formed by the fingers.
D. displacing the skin by pulling the skin down or to one side about 1 inch with the non-dominant hand before administering the injection.
Explanation: The vastus lateralis is correctly located by dividing the thigh into thirds between the greater trochanter and knee, with the middle third being the injection site.
Question 2 of 5.
A 60-year-old male client comes into the emergency department with a complaint of crushing substernal chest pain that radiates to his shoulder and left arm. The admitting diagnosis is acute myocardial infarction (MI). Immediate admission orders include oxygen by nasal cannula at 4 L/minute, blood work, a chest radiograph, a 12-lead electrocardiogram (ECG), and 2 mg of morphine sulfate given I.V. The nurse should first:
A. Administer the morphine.
B. Obtain a 12-lead ECG.
C. Obtain the blood work.
D. Order the chest radiograph.
Explanation: Administering morphine first relieves pain, reducing myocardial oxygen demand and stabilizing the client. ECG and blood work follow to confirm diagnosis, but pain management is the priority.
Question 3 of 5.
If a client displays risk factors for coronary artery disease, such as smoking cigarettes, eating a diet high in saturated fat, or leading a sedentary lifestyle, techniques of behavior modification may be used to help the client change the behavior. The nurse can best reinforce new adaptive behaviors by:
A. Explaining how the old behavior leads to poor health.
B. Withholding praise until the new behavior is well established.
C. Rewarding the client whenever the acceptable behavior is performed.
D. Instilling mild fear into the client to extinguish the behavior.
Explanation: Positive reinforcement, such as rewarding adaptive behaviors, encourages the client to continue healthy habits. Fear or delayed praise is less effective for behavior modification.
Question 4 of 5.
Which of the following is not a risk factor for the development of atherosclerosis?
A. A family history of early heart attack.
B. Late onset of puberty.
C. Total blood cholesterol level greater than 220 mg/dL.
D. Elevated fasting blood glucose concentration.
Explanation: Late onset of puberty is not a risk factor for atherosclerosis. Family history, high cholesterol, and elevated glucose are established risk factors.
Question 5 of 5.
The nurse's discharge teaching plan for the client with heart failure should stress the importance of which of the following?
A. Maintaining a high-fiber diet.
B. Walking 2 miles every day.
C. Obtaining daily weights at the same time each day.
D. Remaining sedentary for most of the day.
Explanation: Daily weights at the same time detect fluid retention early, a key strategy to prevent heart failure exacerbations.
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