NCLEX RN Questions Medical Surgical Nursing
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Question 1 of 5.
The wife of a terminally ill client asks the nurse, 'Why is my husband having frequent bowel movements if he is not eating?' Which of the following responses by the nurse informs the wife about the client's condition?
A. I know he is having frequent loose stools and it is distressing for you, but that's just the way it is.
B. I don't know when the bowels will shut down, but they will eventually.
C. The pain medication will eventually help to slow the process of bowel function.
D. The intestines still produce some waste products even when a person is not eating.
Explanation: The intestines continue to produce waste from residual secretions and cellular turnover, even with minimal intake, explaining the frequent bowel movements.
Question 2 of 5.
A client has chest pain rated at 8 on a 10 point visual analog scale. The 12-lead electrocardiogram reveals ST elevation in the inferior leads and Troponin levels are elevated. What is the highest priority for nursing management of this client at this time?
A. Monitor daily weights and urine output.
B. Permit unrestricted visitation by family and friends.
C. Provide client education on medications and diet.
D. Reduce pain and myocardial oxygen demand.
Explanation: The client is experiencing an acute myocardial infarction, indicated by ST elevation and elevated troponin. Reducing pain and myocardial oxygen demand is critical to minimize further cardiac damage.
Question 3 of 5.
When teaching the client with myocardial infarction (MI), the nurse explains that the pain associated with MI is caused by:
A. Left ventricular overload.
B. Impending circulatory collapse.
C. Extracellular electrolyte imbalances.
D. Insufficient oxygen reaching the heart muscle.
Explanation: MI pain results from myocardial ischemia due to insufficient oxygen delivery to the heart muscle, caused by coronary artery occlusion.
Question 4 of 5.
Crackles heard on lung auscultation indicate which of the following?
A. Cyanosis.
B. Bronchospasm.
C. Airway narrowing.
D. Fluid-filled alveoli.
Explanation: Crackles indicate fluid in the alveoli, often due to pulmonary edema in heart failure or post-MI, reflecting left ventricular dysfunction.
Question 5 of 5.
A client with chronic heart failure has atrial fibrillation and a left ventricular ejection fraction of 15%. The client is taking warfarin (Coumadin). The expected outcome of this drug is to:
A. Decrease circulatory overload.
B. Improve the myocardial workload.
C. Prevent thrombus formation.
D. Regulate cardiac rhythm.
Explanation: Warfarin prevents thrombus formation, critical in atrial fibrillation and low ejection fraction, which increase clot risk due to stasis.