Medical-Surgical Nursing NCLEX Exam (): Questions and Verified Correct Answers with Rationales. Best Grade.
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Course
Medical surgical nursing
Institution
Medical Surgical Nursing
1.
The nursing care plan for a toddler diagnosed with Kawasaki Disease (mucocutaneous lymph node syndrome) should be based on the high risk for development of which problem?
A.
Chronic vessel plaque formation
B.
Pulmonary embolism
C.
Occlusions at the vessel bifurcations
D.
Coronary artery...
Medical-Surgical Nursing NCLEX Exam
(2024-2025): Questions and Verified Correct
Answers. Best Grade.
1. The nursing care plan for a toddler diagnosed with Kawasaki Disease (mucocutaneous lymph node
syndrome) should be based on the high risk for development of which problem?
A. Chronic vessel plaque formation
B. Pulmonary embolism
C. Occlusions at the vessel bifurcations
D. Coronary artery aneurysms
The correct answer is D: Coronary artery aneurysms. Kawasaki Disease involves all the small and
medium-sized blood vessels. There is progressive inflammation of the small vessels which progresses
to the medium-sized muscular arteries, potentially damaging the walls and leading to coronary artery
aneurysms.
2. A nurse has just received a medication order which is not legible. Which statement best reflects assertive
communication?
A. “I cannot give this medication as it is written. I have no idea of what you mean.”
B. “Would you please clarify what you have written so I am sure I am reading it correctly?”
C. “I am having difficulty reading your handwriting. It would save me time if you would be more
careful.”
D. “Please print in the future so I do not have to spend extra time attempting to read your writing.”
The correct answer is B: “Would you please clarify what you have written so I am sure I am
reading it correctly?”Assertive communication respects the rights and responsibilities of both
parties. This statement is an honest expression of concern for safe practice and a request for
clarification without self-depreciation. It reflects the right of the professional to give and receive
information.
3. The nurse is discussing negativism with the parents of a 30 month-old child. How should the nurse tell
the parents to best respond to this behavior?
A. Reprimand the child and give a 15 minute “time out”
B. Maintain a permissive attitude for this behavior
C. Use patience and a sense of humor to deal with this behavior
D. Assert authority over the child through limit setting
The correct answer is C: Use patience and a sense of humor to deal with this behavior. The
nurse should help the parents see the negativism as a normal growth of autonomy in the toddler.
They can best handle the negative toddler by using patience and humor.
,4. An ambulatory client reports edema during the day in his feet and an ankle that disappears while
sleeping at night. What is the most appropriate follow-up question for the nurse to ask?
A. “Have you had a recent heart attack?”
B. “Do you become short of breath during your normal daily activities?”
C. “How many pillows do you use at night to sleep comfortably?”
D. “Do you smoke?”
The correct answer is B: “Do you become short of breath during your normal daily
activities?”. These are the symptoms of right-sided heart failure, which causes increased pressure
in the systemic venous system. To equalize this pressure, the fluid shifts into the interstitial spaces
causing edema. Because of gravity, the lower extremities are first affected in an ambulatory patient.
This question would elicit information to confirm the nursing diagnosis of activity intolerance and
fluid volume excess both associated with right-sided heart failure.
5. The nurse is planning care for a client during the acute phase of a sickle cell vaso-occlusive crisis.
Which of the following actions would be most
appropriate?
A. Fluid restriction 1000cc per day
B. Ambulate in hallway 4 times a day
C. Administer analgesic therapy as ordered
D. Encourage increased caloric intake
The correct answer is C: Administer analgesic therapy as ordered. The main general objectives
in the treatment of a sickle cell crisis is bed rest, hydration, electrolyte replacement, analgesics for
pain, blood replacement and antibiotics to treat any existing infection
6. While working with an obese adolescent, it is important for the nurse to recognize that obesity in
adolescents is most often associated with what
other behavior?
A. Sexual promiscuity
B. Poor body image
C. Dropping out of school
D. Drug experimentation
The correct answer is B: Poor body image. As the adolescent gains weight, there is a lessening
sense of self esteem and poor body image.
7. A nurse and client are talking about the client’s progress toward understanding his behavior under stress.
This is typical of which phase in the
therapeutic relationship?
, A. Pre-interaction
B. Orientation
C. Working
D. Termination
The correct answer is C: Working. During the working phase alternative behaviors and
techniques are explored. The nurse and the client discuss the meaning behind the behavior.
8. A nurse is eating in the hospital cafeteria when a toddler at a nearby table chokes on a piece of food and
appears slightly blue. The appropriate initial
action should be to
A. Begin mouth to mouth resuscitation
B. Give the child water to help in swallowing
C. Perform 5 abdominal thrusts
D. Call for the emergency response team
The correct answer is C: Perform 5 abdominal thrusts. At this age, the most effective way to
clear the airway of food is to perform abdominal thrusts.
9. The emergency room nurse admits a child who experienced a seizure at school. The father comments
that this is the first occurrence, and denies any family history of epilepsy. What is the best response by
the nurse?
A. “Do not worry. Epilepsy can be treated with medications.”
B. “The seizure may or may not mean your child has epilepsy.”
C. “Since this was the first convulsion, it may not happen again.”
D. “Long term treatment will prevent future seizures.”
The correct answer is B: “The seizure may or may not mean your child has epilepsy.” There
are many possible causes for a childhood seizure. These include fever, central nervous system
conditions, trauma, metabolic alterations and idiopathic (unknown).
10. A nurse admits a 3 week-old infant to the special care nursery with a diagnosis of bronchopulmonary
dysplasia. As the nurse reviews the birth
history, which data would be most consistent with this diagnosis?
A. Gestational age assessment suggested growth retardation
B. Meconium was cleared from the airway at delivery
C. Phototherapy was used to treat Rh incompatibility
D. The infant received mechanical ventilation for 2 weeks
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