Free NCLEX Medical Surgical Nursing Questions and Answers 3

Question 1

A nurse is caring for a client with acute pancreatitis. Which assessment finding is the priority concern?

Accepted Answer

Blood pressure of 88/54 mmHg

Answer

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?

Accepted Answer

Spironolactone (Aldactone)

Answer

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?

Accepted Answer

Tingling around the mouth and carpopedal spasm

Answer

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?

Accepted Answer

Continuous bubbling in the water-seal chamber

Answer

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?

Accepted Answer

Hold the client's metformin dose

Answer

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.

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Free NCLEX Medical Surgical Nursing Questions and Answers 3