Free NCLEX Medical Surgical Nursing Questions and Answers 3 — Questions and Answers
Question 1: A nurse is caring for a client with acute pancreatitis. Which assessment finding is the priority concern?
- Serum lipase level of 450 U/L
- Blood pressure of 88/54 mmHg (Correct answer)
- Abdominal pain rated 7/10
- Nausea with two episodes of vomiting
Correct answer: Blood pressure of 88/54 mmHg
Acute pancreatitis causes systemic inflammatory response syndrome (SIRS) leading to fluid shifts and hypovolemia. A sudden drop in blood pressure to 88/54 mmHg indicates hemodynamic instability, which is a life-threatening emergency requiring immediate intervention. Airway, breathing, and circulation (ABCs) always take priority.
Question 2: A client with chronic kidney disease (CKD) stage 4 has a serum potassium of 6.2 mEq/L. Which medication should the nurse question?
- Calcium carbonate (Tums)
- Sodium bicarbonate
- Spironolactone (Aldactone) (Correct answer)
- Furosemide (Lasix)
Correct answer: Spironolactone (Aldactone)
Spironolactone is a potassium-sparing diuretic. In a client with CKD who already has hyperkalemia (K+ 6.2 mEq/L, normal 3.5–5.0), administering spironolactone would further elevate potassium levels and risk life-threatening cardiac dysrhythmias. The nurse must question this order before administration.
Question 3: A nurse is assessing a client post-thyroidectomy. Which finding requires immediate intervention?
- Hoarse voice immediately after surgery
- Serum calcium of 9.0 mg/dL
- Mild sore throat when swallowing
- Tingling around the mouth and carpopedal spasm (Correct answer)
Correct answer: Tingling around the mouth and carpopedal spasm
Tingling and numbness around the mouth (circumoral paresthesia) and carpopedal spasm (positive Trousseau sign) indicate hypocalcemia caused by accidental removal or damage to the parathyroid glands during thyroidectomy. Severe hypocalcemia can lead to laryngospasm, tetany, and respiratory arrest — a surgical emergency requiring immediate IV calcium gluconate.
Question 4: A nurse is caring for a client with a newly placed chest tube for a pneumothorax. Which observation requires immediate action?
- Fluctuation (tidaling) in the water-seal chamber with breathing
- Drainage of 30 mL of serosanguineous fluid in the past hour
- Continuous bubbling in the water-seal chamber (Correct answer)
- Suction chamber bubbling at the prescribed level
Correct answer: Continuous bubbling in the water-seal chamber
Continuous bubbling in the water-seal chamber (after the initial evacuation period) indicates an air leak. This could mean the chest tube has become disconnected, kinked, or there is a persistent bronchopleural fistula. An unresolved air leak prevents lung re-expansion and must be addressed immediately to avoid tension pneumothorax.
Question 5: A client with type 2 diabetes is scheduled for a CT scan with contrast dye. Which action should the nurse take first?
- Ensure the client has signed informed consent
- Hold the client's metformin dose (Correct answer)
- Start a peripheral IV for contrast administration
- Check the client's most recent blood glucose
Correct answer: Hold the client's metformin dose
Metformin must be held before contrast dye administration because iodinated contrast agents can cause acute kidney injury, which would impair metformin excretion. Metformin accumulation in the presence of renal impairment leads to lactic acidosis, a life-threatening condition. The priority action is to hold metformin prior to the procedure.
Question 6: A nurse is caring for a client with cirrhosis who has developed hepatic encephalopathy. Which dietary instruction is most appropriate?
- Increase red meat intake to promote liver cell regeneration
- Eliminate all protein from the diet to prevent ammonia production
- Emphasize plant-based and dairy proteins over red meat (Correct answer)
- Follow a high-fat diet to spare protein catabolism
Correct answer: Emphasize plant-based and dairy proteins over red meat
In hepatic encephalopathy, the liver cannot metabolize ammonia produced from protein breakdown. While protein is essential for healing, the type matters: plant-based proteins and dairy proteins produce less ammonia than animal/red meat proteins. Clients should consume moderate amounts of plant-based protein rather than severely restricting or eliminating protein, which would worsen malnutrition.
Free NCLEX Medical Surgical Nursing Questions and Answers 3
A nurse is caring for a client with acute pancreatitis.
Which assessment finding is the priority concern?