Free NCLEX Medical Surgical Nursing Questions and Answers 2 — Questions and Answers
Question 1: A nurse is caring for a client with acute myocardial infarction who is receiving IV morphine sulfate. Which finding requires the nurse to take immediate action?
- Respiratory rate of 10 breaths per minute (Correct answer)
- Blood pressure of 100/70 mmHg
- Pain rating of 4/10
- Heart rate of 88 beats per minute
Correct answer: Respiratory rate of 10 breaths per minute
Morphine can cause respiratory depression, a life-threatening complication. A respiratory rate below 12 breaths/min requires immediate intervention and possible administration of naloxone.
Question 2: A postoperative client who had abdominal surgery 2 days ago reports sudden onset of shortness of breath and pleuritic chest pain. The nurse suspects pulmonary embolism. What is the priority nursing action?
- Administer oxygen and notify the physician immediately (Correct answer)
- Obtain a 12-lead ECG and document findings
- Elevate the affected leg and apply a warm compress
- Encourage deep breathing and incentive spirometry
Correct answer: Administer oxygen and notify the physician immediately
When pulmonary embolism is suspected, the priority is to maintain oxygenation. Administering oxygen immediately addresses the hypoxemia while the nurse notifies the physician and prepares for further diagnostics.
Question 3: A client with type 2 diabetes mellitus is scheduled for a CT scan with contrast dye. Which medication should the nurse anticipate holding before and after the procedure?
- Metformin (Glucophage) (Correct answer)
- Glipizide (Glucotrol)
- Insulin glargine (Lantus)
- Sitagliptin (Januvia)
Correct answer: Metformin (Glucophage)
Metformin must be held before and after contrast dye administration because contrast agents can impair renal function, leading to metformin accumulation and a risk of lactic acidosis.
Question 4: A nurse is assessing a client with chronic obstructive pulmonary disease (COPD) who is receiving oxygen at 2 L/min via nasal cannula. The client becomes increasingly confused and lethargic. Which action should the nurse take first?
- Assess oxygen saturation and notify the physician (Correct answer)
- Increase the oxygen flow rate to 4 L/min
- Encourage the client to cough and deep breathe
- Reorient the client and dim the room lights
Correct answer: Assess oxygen saturation and notify the physician
Confusion and lethargy in a COPD patient on oxygen may indicate CO2 narcosis from excessive oxygen suppressing the hypoxic drive. The nurse should assess oxygen saturation and arterial blood gases, and reduce O2 flow if indicated while notifying the physician.
Question 5: Among the following signs and symptoms, which cluster indicates a client is experiencing cardiogenic shock following an acute MI?
- Hypotension, tachycardia, cool clammy skin, and decreased urine output (Correct answer)
- Hypertension, bradycardia, flushed warm skin, and polyuria
- Normal blood pressure, bradycardia, diaphoresis, and nausea
- Hypotension, bradycardia, warm dry skin, and normal urine output
Correct answer: Hypotension, tachycardia, cool clammy skin, and decreased urine output
Cardiogenic shock results from severely reduced cardiac output. The hallmarks include hypotension, tachycardia, cool/clammy skin from peripheral vasoconstriction, and decreased urine output reflecting poor renal perfusion.
Question 6: Because older adults frequently underreport pain, the nurse must carefully evaluate pain in this population. Which assessment approach is most appropriate for an elderly client with moderate dementia who has had a hip replacement?
- Use a behavioral pain scale such as PAINAD to assess nonverbal cues (Correct answer)
- Ask the client to rate pain on a numeric scale from 0 to 10
- Administer routine analgesics only when the client requests them
- Rely solely on vital signs to determine the presence of pain
Correct answer: Use a behavioral pain scale such as PAINAD to assess nonverbal cues
Clients with dementia may be unable to self-report pain reliably. Behavioral pain scales such as PAINAD observe nonverbal cues like facial expressions, vocalizations, and body language to provide a more accurate pain assessment.
Free NCLEX Medical Surgical Nursing Questions and Answers 2
A nurse is caring for a client with acute myocardial infarction who is receiving IV morphine sulfate.
Which finding requires the nurse to take immediate action?