Adult Medical-Surgical NCLEX-RN Exam Questions And Correct Answers
1. A nurse reviews the laboratory results of a client receiving a continuous intravenous heparin
infusion for a deep vein thrombosis. The client's activated partial thromboplastin time (aPTT) is 110
26
seconds. Which action should the nurse take first?
A. Stop the heparin infusion.
B. Infuse protamine sulfate.
C. Repeat the laboratory test.
20
D. Document the finding.
Correct Answer: A
2. A nurse assesses a client who is 6 hours postoperative following a thyroidectomy. The client
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reports tingling around the mouth and fingers. Which action should the nurse take immediately?
A. Check the client's serum calcium level.
B. Assess for Trousseau's sign.
C. Notify the healthcare provider.
D. Administer an oral calcium supplement.
Ex
Correct Answer: B
3. A nurse cares for a client with a chest tube attached to a water-seal drainage system.The nurse
notes continuous bubbling in the water-seal chamber. How should the nurse interpret this
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finding?
A. The system is functioning normally.
B. There is a leak in the drainage system.
C. The client's lung has fully re-expanded.
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D. The suction pressure is set too high.
Correct Answer: B
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4. A nurse prioritizes care for a group of clients on a telemetry unit. Which client should the nurse
assess first?
A. A client with atrial fibrillation with a heart rate of 88 beats/min.
N
B. A client with sinus bradycardia who is reporting lightheadedness.
C. A client with a permanent pacemaker and a heart rate of 72 beats/min.
D. A client with first-degree heart block and a PR interval of 0.24
seconds.Correct Answer: B
,5. A nurse provides discharge teaching to a client diagnosed with chronic obstructive
pulmonary disease (COPD). Which statement by the client indicates a need for further
26
instruction?
A. "I will eat small, frequent meals that are high in calories."
B. "I will practice pursed-lip breathing when I feel short of breath."
20
C. "I will increase my oxygen flow rate if I feel extra tired."
am
Ex
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si
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N
,D. "I will get my annual influenza vaccine every autumn."
Correct Answer: C
6. A nurse cares for a client presenting to the emergency department with suspected acute
myocardial infarction. Which prescription should the nurse implement first?
A. Obtain a 12-lead electrocardiogram (ECG).
B. Administer morphine sulfate 2 mg intravenously.
C. Draw blood for troponin levels.
26
D. Administer oxygen 2 L/min via nasal cannula.
Correct Answer: A
7. A nurse assesses a client with cirrhosis who has developed hepatic encephalopathy.Which clinical
manifestation shouId the nurse expect?
20
A. Hyperreflexia and tremors
B. Asterixis and confusion
C. Ascites and shifting dullness
D. Splenomegaly and pruritus
Correct Answer: B
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8. A nurse monitors a client receiving blood transfusion therapy. Fifteen minutes after the start of the
infusion, the client develops chills, fever, and low back pain. Which action should the nurse take first?
A. Notify the blood bank.
Ex
B. Stop the infusion.
C. Administer acetaminophen.
D. Flush the line with normal saline.
Correct Answer: B
9. A nurse provides education to a client newly diagnosed with type 1 diabetes mellitus regarding foot
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care. Which instruction should the nurse include?
A. Soak your feet daily in warm water to soften calluses.
B. Use a heating pad to keep your feet warm at night.
si
C. Cut your toenails in a rounded shape close to the skin.
D. Inspect the bottoms of your feet daily using a mirror.
Correct Answer: D
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10. A nurse cares for a client with acute pancreatitis. Which laboratory result should the nurse expect
to be elevated?
A. Serum calcium
N
B. Serum amylase
C. Serum potassium
D. Serum albumin
Correct Answer: B
, Pharmacology & Parenteral Therapies
11. A nurse prepares to administer digoxin 0.25 mg intravenously to a client with heart failure. Which
action is essential before administration?
A. Assess the client's blood pressure.
B. Measure the apical pulse rate for one full minute.
C. Check the client's serum sodium level.
26
D. Monitor the client's urine output.
Correct Answer: B
12. A client is prescribed oral warfarin therapy. WWhich dietary instruction should the nurse provide to
20
ensure safety?
A. Avoid foods high in vitamin K entirely.
B. Maintain a consistent intake of foods high in vitamin K.
C. Increase intake of dark green leafy vegetables.
D. Drink grapefruit juice daily to increase absorption.
Correct Answer: B
am
13. A nurse monitors a client receiving a loading dose of intravenous magnesium sulfate for severe
preeclampsia. Which findingrequires immediate intervention?
A. Absent deep tendon reflexes
Ex
B. Urinary output of 40 mL/hour
C. Respiratory rate of 16 breaths/minute
=D. Flushing and a feeling of warmth
Correct Answer: A
14. A nurse prepares to administer regular insulin and NPH insulin in the same syringe.Put the
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preparation steps in the correct chronological order.
1. Inject air into the NPH insulin vial.
2. Inject air into the regular insulin vial.
si
3. Withdraw the prescribed amount of regular insulin.
4. Withdraw the prescriboed amount of NPH insulin.
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A.1,2,3,4
B. 2, 1, 4, 3
C.1,3,2,4
D.2,3,1,4
N
Correct Answer: A
15. A nurse cares for a client receiving a peripheral intravenous infusion of amiodarone.The nurse notes
erythema, warmth, and swelling at the insertion site. Which action should the nurse take?
A. Slow the infusion rate down by half.
B. Apply a cold compress and continue the infusion.
C. Stop the infusion and remove the catheter.
D. Flush the intravenous line with normal saline.
Correct Answer: C
1. A nurse reviews the laboratory results of a client receiving a continuous intravenous heparin
infusion for a deep vein thrombosis. The client's activated partial thromboplastin time (aPTT) is 110
26
seconds. Which action should the nurse take first?
A. Stop the heparin infusion.
B. Infuse protamine sulfate.
C. Repeat the laboratory test.
20
D. Document the finding.
Correct Answer: A
2. A nurse assesses a client who is 6 hours postoperative following a thyroidectomy. The client
am
reports tingling around the mouth and fingers. Which action should the nurse take immediately?
A. Check the client's serum calcium level.
B. Assess for Trousseau's sign.
C. Notify the healthcare provider.
D. Administer an oral calcium supplement.
Ex
Correct Answer: B
3. A nurse cares for a client with a chest tube attached to a water-seal drainage system.The nurse
notes continuous bubbling in the water-seal chamber. How should the nurse interpret this
ng
finding?
A. The system is functioning normally.
B. There is a leak in the drainage system.
C. The client's lung has fully re-expanded.
si
D. The suction pressure is set too high.
Correct Answer: B
ur
4. A nurse prioritizes care for a group of clients on a telemetry unit. Which client should the nurse
assess first?
A. A client with atrial fibrillation with a heart rate of 88 beats/min.
N
B. A client with sinus bradycardia who is reporting lightheadedness.
C. A client with a permanent pacemaker and a heart rate of 72 beats/min.
D. A client with first-degree heart block and a PR interval of 0.24
seconds.Correct Answer: B
,5. A nurse provides discharge teaching to a client diagnosed with chronic obstructive
pulmonary disease (COPD). Which statement by the client indicates a need for further
26
instruction?
A. "I will eat small, frequent meals that are high in calories."
B. "I will practice pursed-lip breathing when I feel short of breath."
20
C. "I will increase my oxygen flow rate if I feel extra tired."
am
Ex
ng
si
ur
N
,D. "I will get my annual influenza vaccine every autumn."
Correct Answer: C
6. A nurse cares for a client presenting to the emergency department with suspected acute
myocardial infarction. Which prescription should the nurse implement first?
A. Obtain a 12-lead electrocardiogram (ECG).
B. Administer morphine sulfate 2 mg intravenously.
C. Draw blood for troponin levels.
26
D. Administer oxygen 2 L/min via nasal cannula.
Correct Answer: A
7. A nurse assesses a client with cirrhosis who has developed hepatic encephalopathy.Which clinical
manifestation shouId the nurse expect?
20
A. Hyperreflexia and tremors
B. Asterixis and confusion
C. Ascites and shifting dullness
D. Splenomegaly and pruritus
Correct Answer: B
am
8. A nurse monitors a client receiving blood transfusion therapy. Fifteen minutes after the start of the
infusion, the client develops chills, fever, and low back pain. Which action should the nurse take first?
A. Notify the blood bank.
Ex
B. Stop the infusion.
C. Administer acetaminophen.
D. Flush the line with normal saline.
Correct Answer: B
9. A nurse provides education to a client newly diagnosed with type 1 diabetes mellitus regarding foot
ng
care. Which instruction should the nurse include?
A. Soak your feet daily in warm water to soften calluses.
B. Use a heating pad to keep your feet warm at night.
si
C. Cut your toenails in a rounded shape close to the skin.
D. Inspect the bottoms of your feet daily using a mirror.
Correct Answer: D
ur
10. A nurse cares for a client with acute pancreatitis. Which laboratory result should the nurse expect
to be elevated?
A. Serum calcium
N
B. Serum amylase
C. Serum potassium
D. Serum albumin
Correct Answer: B
, Pharmacology & Parenteral Therapies
11. A nurse prepares to administer digoxin 0.25 mg intravenously to a client with heart failure. Which
action is essential before administration?
A. Assess the client's blood pressure.
B. Measure the apical pulse rate for one full minute.
C. Check the client's serum sodium level.
26
D. Monitor the client's urine output.
Correct Answer: B
12. A client is prescribed oral warfarin therapy. WWhich dietary instruction should the nurse provide to
20
ensure safety?
A. Avoid foods high in vitamin K entirely.
B. Maintain a consistent intake of foods high in vitamin K.
C. Increase intake of dark green leafy vegetables.
D. Drink grapefruit juice daily to increase absorption.
Correct Answer: B
am
13. A nurse monitors a client receiving a loading dose of intravenous magnesium sulfate for severe
preeclampsia. Which findingrequires immediate intervention?
A. Absent deep tendon reflexes
Ex
B. Urinary output of 40 mL/hour
C. Respiratory rate of 16 breaths/minute
=D. Flushing and a feeling of warmth
Correct Answer: A
14. A nurse prepares to administer regular insulin and NPH insulin in the same syringe.Put the
ng
preparation steps in the correct chronological order.
1. Inject air into the NPH insulin vial.
2. Inject air into the regular insulin vial.
si
3. Withdraw the prescribed amount of regular insulin.
4. Withdraw the prescriboed amount of NPH insulin.
ur
A.1,2,3,4
B. 2, 1, 4, 3
C.1,3,2,4
D.2,3,1,4
N
Correct Answer: A
15. A nurse cares for a client receiving a peripheral intravenous infusion of amiodarone.The nurse notes
erythema, warmth, and swelling at the insertion site. Which action should the nurse take?
A. Slow the infusion rate down by half.
B. Apply a cold compress and continue the infusion.
C. Stop the infusion and remove the catheter.
D. Flush the intravenous line with normal saline.
Correct Answer: C
