NCLEX RN Medical Surgical Questions and Answers
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Question 1 of 5.
Extract:The following scenario applies to the next 1 items The emergency department nurse cares for a child with otitis media Item 1 of 1 Nurses' Note Vital Signs Orders 1815: 10-year-old-male arrives at the emergency department (ED) after reporting a fever, left ear pain, and malaise that started three days ago and has worsened. The client's father reports that he was at a pool party a few days before the symptoms started. The child is alert and fully oriented. Warm to touch and reports that 'it hurts a lot.' The left ear was slightly reddened with no drainage. Peripheral pulses were palpable. Lung sounds were clear. Reports no coughing or other symptoms. The child does not have any medical history. No known allergies. Current on all immunizations. Current weight is 33 kilograms (kg).
The nurse should administer the ceftriaxone in the client's ............................……. to prevent............................……….. The nurse should obtain a prescription for ............................…. cream to apply one hour before the injection to decrease the child's pain.
A. ventrogluteal
B. dorsogluteal
C. Abdomen
D. nerve damage.
E. staining of the skin
F. hydrocortisone
G. EMLA (lidocaine and prilocaine)
Explanation: Ceftriaxone should be administered in the ventrogluteal site to avoid nerve damage; EMLA cream reduces pain when applied an hour prior.
Question 2 of 5.
The nurse has completed an assessment on a client with a decreased cardiac output. Which findings should receive the highest priority?
A. BP 110/62, atrial fibrillation with HR 82, bibasilar crackles.
B. Confusion, urine output 15 mL over the last 2 hours, orthopnea.
C. SpO2 92 on 2 liters nasal cannula, respirations 20, 1+ edema of lower extremities.
D. Weight gain of 1 kg in 3 days, BP 130/80, mild dyspnea with exercise.
Explanation: Confusion, low urine output, and orthopnea indicate severe heart failure with potential cerebral and renal hypoperfusion, requiring immediate intervention. Other options reflect stable or less urgent findings.
Question 3 of 5.
Which of the following reflects the principle on which a client's diet will most likely be based during the acute phase of myocardial infarction?
A. Liquids as desired.
B. Small, easily digested meals.
C. Three regular meals per day.
D. Nothing by mouth.
Explanation: Small, easily digested meals reduce the metabolic demand on the heart and prevent gastrointestinal distress, which could exacerbate myocardial oxygen demand during the acute phase of MI.
Question 4 of 5.
Which of the following symptoms should the nurse teach the client with unstable angina to report immediately to her physician?
A. A change in the pattern of her pain.
B. Pain during sexual activity.
C. Pain during an argument with her husband.
D. Pain during or after an activity such as lawn-mowing.
Explanation: A change in the pattern of angina pain may indicate worsening ischemia or progression to unstable angina or MI, requiring immediate medical attention.
Question 5 of 5.
A client receiving a loop diuretic should be encouraged to eat which of the following foods? Select all that apply.
A. Angel food cake.
B. Banana.
C. Dried fruit.
D. Orange juice.
E. Peppers.
Explanation: Loop diuretics like furosemide cause potassium loss. Bananas (B), dried fruit (C), and orange juice (D) are potassium-rich, helping prevent hypokalemia.
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