NCLEX RN Medical Surgical Practice Questions
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Question 1 of 5.
Extract:The following scenario applies to the next 1 items The nurse in the intensive care unit (ICU) has completed an assessment on a client Item 1 of 1 Nurses' Notes Orders 1923: Assessment completed. Peripheral vascular access device (PAD) was assessed. Erythema and swelling were noted at the insertion site. The client reported "severe" pain, and tenderness was endorsed when it was palpated. The infusion was stopped.
The nurse reviews the assessment and is preparing to take action. For each potential action, click to specify whether the potential action is indicated or not indicated for the client.
| Description | Options |
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| Lorem ipsum dolor sit amet consectetur. |
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| Lorem ipsum dolor sit amet consectetur. |
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| Lorem ipsum dolor sit amet consectetur. |
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Explanation: Removing the PVAD, notifying the physician, and disconnecting the administration set are indicated for infiltration; flushing is not indicated, and phentolamine is for extravasation.
Question 2 of 5.
A client with chest pain is prescribed intravenous nitroglycerin (Tridil). Which assessment is of greatest concern for the nurse initiating the nitroglycerin drip?
A. Serum potassium is 3.5 mEq/L.
B. Blood pressure is 88/46.
C. ST elevation is present on the electrocardiogram.
D. Heart rate is 61.
Explanation: Nitroglycerin causes vasodilation, which can lower blood pressure. A blood pressure of 88/46 indicates hypotension, a significant concern as it may compromise perfusion, making it the priority assessment.
Question 3 of 5.
The nurse is assessing a client who has had a myocardial infarction. The nurse notes the cardiac rhythm shown on the electrocardiogram strip below. The nurse identifies this rhythm as which of the following?
A. Atrial fibrillation.
B. Ventricular tachycardia.
C. Premature ventricular contractions.
D. Sinus tachycardia.
Explanation: Sinus tachycardia is a fast but regular rhythm originating from the sinoatrial node, typically occurring in response to factors like pain, fever, anxiety, or myocardial infarction.
Question 4 of 5.
A 68-year-old female client on day 2 after hip surgery has no cardiac history but reports having chest heaviness. The first nursing action should be to:
A. Inquire about the onset, duration, severity, and precipitating factors of the heaviness.
B. Administer oxygen via nasal cannula.
C. Offer pain medication for the chest heaviness.
D. Inform the physician of the chest heaviness.
Explanation: Assessing the characteristics of chest heaviness clarifies whether it is cardiac (e.g., angina) or non-cardiac, guiding further actions like oxygen or physician notification.
Question 5 of 5.
A client has a history of heart failure and has been taking several medications, including furosemide (Lasix), digoxin (Lanoxin) and potassium chloride. The client has nausea, blurred vision, headache, and weakness. The nurse notes that the client is confused. The telemetry strip shows first-degree atrioventricular block. The nurse should assess the client for signs of which condition?
A. Hyperkalemia.
B. Digoxin toxicity.
C. Fluid deficit.
D. Pulmonary edema.
Explanation: Nausea, blurred vision, confusion, and AV block are classic signs of digoxin toxicity, especially in a client taking digoxin, requiring immediate assessment.
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