NCLEX RN 2024 MEDICAL SURGICAL EXAM TEST BANK WITH
RATIONALISED ANSWERS
100% ACCURATE GRADED A+
1. The second day after admission with a fractured pelvis, a 64-year-old patient suddenly develops confusion. Which
action should the nurse take first?
a.Take the blood pressure.
b.Assess patient orientation.
c.Check the oxygen saturation.
d.Observe for facial asymmetry. - ANSWERS-ANS: C
The patient's history and clinical manifestations suggest a fat embolus. The most important assessment is
oxygenation. The other actions are also appropriate but will be done after the nurse assesses gas exchange.
2. A client with cor pulmonale secondary to chronic obstructive pulmonary disease (COPD) is being discharged home
on oxygen therapy at 2 L nasal cannula via portable oxygen tank. What information does the nurse include when
teaching about home oxygen use?
a. "Ensure you have a regular delivery schedule and a spare source of oxygen available."
b. "Do not allow open flame or smoking in the room where oxygen is being used."
c. "Replace the nasal cannula and tubing every week or more often if soiled."
d. "Even if your dyspnea is worse, never allow the administration of oxygen above three liters."
e. "If you are not experiencing any dyspnea, remove the oxygen to reduce dependence." - ANSWERS-"Ensure
you have a regular delivery schedule and a spare source of oxygen available."
"Do not allow open flame or smoking in the room where oxygen is being used.
3. A client with burn injuries has a carbon monoxide level of 45%. The nurse expects which finding based on this
carbon monoxide level?
a. Tachycardia
1
, b. Headache
c. Impaired visual acuity
d. Loss of consciousness - ANSWERS-Loss of consciousness
4. A nurse caring for a client with chronic kidney disease (CKD) monitors which laboratory result, known as the most
reliable in evaluating kidney function?
a. Creatinine clearance
b. Serum creatinine
c. Blood urea nitrogen
d. Urinalysis - ANSWERS-Creatinine clearance
5. The nurse reviews a client's lab results. Which result is likely for a client with Cushing syndrome?
a. The client has low plasma adrenocorticotropic hormone levels.
b. The client has low urine-free cortisol.
c. The client has low 17-ketosteroids.
d. The client has elevated lymphocytes. - ANSWERS-The client has low plasma adrenocorticotropic hormone
levels.
6. The nurse cares for a client admitted with thyroid storm. Which signs and symptoms are likely upon assessment?
a. The client reports frequent constipation.
b. The client's heart rate is 108 beats/min.
c. The client's temperature is 103 °F (39.4 °C).
d. The client's blood pressure is 122/89 mmHg.
2
, e. The client displays tremors in the hands bilaterally. - ANSWERS-The client's heart rate is 108 beats/min.
The client's temperature is 103 °F (39.4 °C).
The client displays tremors in the hands bilaterally.
7. A nurse reviews a medical record for a client with adenocarcinoma in the entire lung with poor cellular
differentiation and metastasis. Which tool is used to describe this cancer?
a. Rule of Nines
b. Morse Scale
c. TNM Classification
d. Braden Scale - ANSWERS-TNM Classification
8. An older adult client with rheumatoid arthritis (RA) asks the nurse what the difference is between RA and
osteoarthritis. Which response does the nurse give to the client?
a. "Osteoarthritis does not generally cause swelling."
b. "Rheumatoid arthritis affects the larger joints."
c. "Rheumatoid arthritis is most common in men."
d. "Osteoarthritis pain generally occurs after periods of inactivity." - ANSWERS-"Osteoarthritis does not
generally cause swelling."
9. A 42-year-old patient is admitted to the emergency department with a left femur fracture. Which information
obtained by the nurse is most important to report to the health care provider?
a.Ecchymosis of the left thigh
b.Complaints of severe thigh pain
3
, c.Slow capillary refill of the left foot
d.Outward pointing toes on the left foot - ANSWERS-ANS: C
Prolonged capillary refill may indicate complications such as arterial damage or compartment syndrome. The other
findings are typical with a left femur fracture.
10. A patient undergoes a left above-the-knee amputation with an immediate prosthetic fitting. When the patient
arrives on the orthopedic unit after surgery, the nurse should
a.place the patient in a prone position.
b.check the surgical site for hemorrhage.
c.remove the prosthesis and wrap the site.
d.keep the residual leg elevated on a pillow. - ANSWERS-ANS: B
The nurse should monitor for hemorrhage after the surgery. The prosthesis will not be removed. To avoid flexion
contracture of the hip, the leg will not be elevated on a pillow. The patient is placed in a prone position after
amputation to prevent hip flexion, but this would not be done during the immediate postoperative period.
11. Before assisting a patient with ambulation 2 days after a total hip replacement, which action is most important for
the nurse to take?
a.Observe the status of the incisional drain device.
b.Administer the ordered oral opioid pain medication.
c.Instruct the patient about the benefits of ambulation.
d.Change the hip dressing and document the wound appearance. - ANSWERS-ANS: B
The patient should be adequately medicated for pain before any attempt to ambulate. Instructions about the benefits
of ambulation may increase the patient's willingness to ambulate, but decreasing pain with ambulation is more
important. The presence of an incisional drain or timing of dressing change will not affect ambulation.
12. The nurse performs the Weber tuning fork test on a client. Which finding indicates the client may have
sensorineural hearing loss in the left ear?
4
RATIONALISED ANSWERS
100% ACCURATE GRADED A+
1. The second day after admission with a fractured pelvis, a 64-year-old patient suddenly develops confusion. Which
action should the nurse take first?
a.Take the blood pressure.
b.Assess patient orientation.
c.Check the oxygen saturation.
d.Observe for facial asymmetry. - ANSWERS-ANS: C
The patient's history and clinical manifestations suggest a fat embolus. The most important assessment is
oxygenation. The other actions are also appropriate but will be done after the nurse assesses gas exchange.
2. A client with cor pulmonale secondary to chronic obstructive pulmonary disease (COPD) is being discharged home
on oxygen therapy at 2 L nasal cannula via portable oxygen tank. What information does the nurse include when
teaching about home oxygen use?
a. "Ensure you have a regular delivery schedule and a spare source of oxygen available."
b. "Do not allow open flame or smoking in the room where oxygen is being used."
c. "Replace the nasal cannula and tubing every week or more often if soiled."
d. "Even if your dyspnea is worse, never allow the administration of oxygen above three liters."
e. "If you are not experiencing any dyspnea, remove the oxygen to reduce dependence." - ANSWERS-"Ensure
you have a regular delivery schedule and a spare source of oxygen available."
"Do not allow open flame or smoking in the room where oxygen is being used.
3. A client with burn injuries has a carbon monoxide level of 45%. The nurse expects which finding based on this
carbon monoxide level?
a. Tachycardia
1
, b. Headache
c. Impaired visual acuity
d. Loss of consciousness - ANSWERS-Loss of consciousness
4. A nurse caring for a client with chronic kidney disease (CKD) monitors which laboratory result, known as the most
reliable in evaluating kidney function?
a. Creatinine clearance
b. Serum creatinine
c. Blood urea nitrogen
d. Urinalysis - ANSWERS-Creatinine clearance
5. The nurse reviews a client's lab results. Which result is likely for a client with Cushing syndrome?
a. The client has low plasma adrenocorticotropic hormone levels.
b. The client has low urine-free cortisol.
c. The client has low 17-ketosteroids.
d. The client has elevated lymphocytes. - ANSWERS-The client has low plasma adrenocorticotropic hormone
levels.
6. The nurse cares for a client admitted with thyroid storm. Which signs and symptoms are likely upon assessment?
a. The client reports frequent constipation.
b. The client's heart rate is 108 beats/min.
c. The client's temperature is 103 °F (39.4 °C).
d. The client's blood pressure is 122/89 mmHg.
2
, e. The client displays tremors in the hands bilaterally. - ANSWERS-The client's heart rate is 108 beats/min.
The client's temperature is 103 °F (39.4 °C).
The client displays tremors in the hands bilaterally.
7. A nurse reviews a medical record for a client with adenocarcinoma in the entire lung with poor cellular
differentiation and metastasis. Which tool is used to describe this cancer?
a. Rule of Nines
b. Morse Scale
c. TNM Classification
d. Braden Scale - ANSWERS-TNM Classification
8. An older adult client with rheumatoid arthritis (RA) asks the nurse what the difference is between RA and
osteoarthritis. Which response does the nurse give to the client?
a. "Osteoarthritis does not generally cause swelling."
b. "Rheumatoid arthritis affects the larger joints."
c. "Rheumatoid arthritis is most common in men."
d. "Osteoarthritis pain generally occurs after periods of inactivity." - ANSWERS-"Osteoarthritis does not
generally cause swelling."
9. A 42-year-old patient is admitted to the emergency department with a left femur fracture. Which information
obtained by the nurse is most important to report to the health care provider?
a.Ecchymosis of the left thigh
b.Complaints of severe thigh pain
3
, c.Slow capillary refill of the left foot
d.Outward pointing toes on the left foot - ANSWERS-ANS: C
Prolonged capillary refill may indicate complications such as arterial damage or compartment syndrome. The other
findings are typical with a left femur fracture.
10. A patient undergoes a left above-the-knee amputation with an immediate prosthetic fitting. When the patient
arrives on the orthopedic unit after surgery, the nurse should
a.place the patient in a prone position.
b.check the surgical site for hemorrhage.
c.remove the prosthesis and wrap the site.
d.keep the residual leg elevated on a pillow. - ANSWERS-ANS: B
The nurse should monitor for hemorrhage after the surgery. The prosthesis will not be removed. To avoid flexion
contracture of the hip, the leg will not be elevated on a pillow. The patient is placed in a prone position after
amputation to prevent hip flexion, but this would not be done during the immediate postoperative period.
11. Before assisting a patient with ambulation 2 days after a total hip replacement, which action is most important for
the nurse to take?
a.Observe the status of the incisional drain device.
b.Administer the ordered oral opioid pain medication.
c.Instruct the patient about the benefits of ambulation.
d.Change the hip dressing and document the wound appearance. - ANSWERS-ANS: B
The patient should be adequately medicated for pain before any attempt to ambulate. Instructions about the benefits
of ambulation may increase the patient's willingness to ambulate, but decreasing pain with ambulation is more
important. The presence of an incisional drain or timing of dressing change will not affect ambulation.
12. The nurse performs the Weber tuning fork test on a client. Which finding indicates the client may have
sensorineural hearing loss in the left ear?
4
