Medical Surgical Nursing NCLEX RN Questions
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Question 1 of 5.
Extract:The nurse in the infusion center is caring for a 27-year-old male. Item 1 of 1 • Nurses' Notes 1401: Orders received for PRBC transfusion. 20-gauge peripheral vascular access device (VAD) started right antecubital space. Blood return was observed, and was flushed with 10 mL of sodium chloride (normal saline) without resistance. The client denied any discomfort at the VAD. Sterile dressing was applied to the VAD. The client was provided verbal education regarding the potential blood transfusion reactions. The client verbalized understanding. 1430: PRBC unit retrieved from blood bank. Vital signs were obtained prior to starting blood transfusion: 99.0° F (37.2° C) P 78, RR 18, BP 130/86, pulse oximetry reading 97% on room air. 1439: Verified and checked client ID and blood product with another RN. Initiated PRBC transfusion via y-type tubing. Will remain with the client for 15 minutes to observe for any potential transfusion-related reaction. 1454: The client denied any manifestations of a transfusion reaction. Vital signs: 99.5°F (37.5°C) P 75, RR 18, BP 132/85, pulse oximetry reading 96% on room air. Increased rate of PRBC transfusion. 1520: The client alerted RN to come to their bedside, reporting pain and discomfort at their VAD. VAD was swollen and cool to the touch. • Orders • Infuse 1 unit of packed red blood cells • Medical History • Sickle cell anemia • Depression
The nurse reviews the clinical data and prepares to take action following the 1520 nursing note entry. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition and 2 parameters the nurse should monitor to assess the client's progress.
Action To take
- A.pause the transfusion and discontinue the vascular access device
- B.discontinue the packed red blood cell transfusion and return it to the blood bank
- C.start a new 20-gauge vascular access device in the opposite extremity
- D.pause the transfusion obtain an order
Potential Condition
- A.febrile transfusion reaction
- B.infiltration at the vascular access device hemolytic transfusion reaction
- C.circulatory overload
Parameter to Monitor
- A.discomfort and swelling at vascular access site
- B.hemoglobin and hematocrit
- C.temperature
- D.blood pressure
Explanation: The nurse should monitor the discomfort and swelling at the VAD site. Pausing the transfusion, elevating the extremity, and applying a compress should alleviate the discomfort and swelling. The nurse will need to monitor the client's hemoglobin and hematocrit to determine the efficacy of the PRBC transfusion. Generally, one unit of PRBCs will raise the hemoglobin by 1 g/dL. It is inappropriate for the nurse to monitor the client's temperature as it pertains to infiltration. The client's temperature is not relevant in managing infiltration. The blood pressure does not require monitoring because it does not show evidence of circulatory overload.
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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