FREE NCLEX Medical Surgical Nursing Questions and Answers 2

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?

Accepted Answer

Respiratory rate of 10 breaths per minute

Answer

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?

Accepted Answer

Administer oxygen and notify the physician immediately

Answer

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?

Accepted Answer

Metformin (Glucophage)

Answer

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?

Accepted Answer

Assess oxygen saturation and notify the physician

Answer

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?

Accepted Answer

Hypotension, tachycardia, cool clammy skin, and decreased urine output

Answer

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.

NCLEX Practice Test

NCLEX Practice Test

FREE NCLEX Medical Surgical Nursing Questions and Answers 2