NCLEX Nursing School Practice Exam
Medical Surgical Practice exam 25 questions
#1. A female client admitted in the coronary care unit (CCU) due to myocardial infarction (MI) has stabilized and is moved with a cardiac monitor via telemetry to the step-down medical unit. The nurse in the medical ward informs the patient that she can perform which of the following activities?
#2. A client is diagnosed with deep vein thrombosis (DVT) and requires IV heparin therapy. While the patient is having this infusion, the nurse should ensure that the nursing unit also has which of the following medications?
Answer: Protamine sulfate
Rationale: Protamine sulfate is the specific antagonist or antidote to heparin. It must be available in the nursing unit to counteract any hemorrhage or excessive bleeding due to IV heparin use. Protamine is able to neutralize anticoagulation from administering heparin. Vitamin K is the antidote for warfarin. Aminocaproic acid is an antifibrinolytic agent, while potassium chloride is used to manage hypokalemia.
#3. An anxious client comes into the emergency room with signs and symptoms of coronary artery disease (CAD). The nurse understands that the first priority of care for this patient is to:
Answer: Improve myocardial oxygenation
Rationale: A client that exhibits signs and symptoms of any cardiac problem must receive immediate care to improve myocardial oxygenation to prevent, reverse, or reduce any damage to the myocardium. This can be achieved by the reduction of ventricular stress using negative inotropic agents, such as beta blockers and calcium channel blockers, as prescribed by the physician. The other options are also important parts of caring for a CAD patient, but resolving the problem with an ischemic myocardium takes the highest priority.
#4. A nurse performs a health education session about myocardial infarction (MI) on a high risk client group. Which of the following should the nurse state as the most common symptom of MI?
Answer: Chest pain
Rationale: Chest pain is the most common symptom of myocardial infarction. It occurs due to the low supply of oxygen to the heart, resulting in myocardial ischemia. MI chest pain usually radiates to the left neck, shoulders, or arms and has no apparent precipitating factors. It often lasts for 20 minutes or more and is usually retrosternal. The patient may describe MI chest pain as a sensation of heaviness or pressure. It can be persistent or intermittent and is not affected by changes in position. The second most common symptom of MI is dyspnea. Palpitation is a sign of arrhythmia, while edema is a late sign of heart failure.
#5. A male client comes into the medical assessment unit with a complaint of knife-like chest pain. Upon interview, the patient rates the chest pain as 7 to 8 out of 10 at rest. He states that the chest pain worsens during inspiration. Which of the following body systems is the most probable origin of this pain?
Rationale: Pulmonary pain is usually sharp, sudden, and can also be described as knife-like. Some conditions of the lungs that may cause pulmonary pain include chest infection, pulmonary embolism, pleurisy, pneumonia, and asthma attack. Cardiac pain feels more of a pressure, heaviness, or tightness in the chest area. Musculoskeletal pain increases with movement, not breathing. Gastrointestinal pain such as due to acid reflux does not change with breathing.