NCLEX Med-Surg Exam #2 Semester Exam
Instructions:Choose the best answer. For select all that apply (SATA), select all
options that are correct.
**1.** The nurse is preparing a client for a lumbar puncture. The client asks, “Why do I have to curl up like a
ball?” Which response by the nurse is most accurate?
- A. “It helps keep you warm during the procedure.”
- B. “It opens the spaces between the vertebrae to insert the needle.”
- C. “It prevents you from moving during the procedure.”
- D. “It reduces the risk of bleeding after the puncture.”
**Correct Answer: B – It opens the spaces between the vertebrae to insert the needle.**
**Rationale:**
- **Correct (B):** Curling into a fetal position (or arching the back) maximizes the space between the spinous
processes, allowing easier access to the subarachnoid space.
- **A:** Position does not affect temperature regulation.
- **C:** The position helps access, but does not prevent movement; the client can still move.
- **D:** Bleeding risk is unaffected by position.
---
**2.** A client is undergoing hemodialysis and develops hypotension, nausea, and headache. The nurse
should take which action first?
- A. Increase the dialysate flow rate
- B. Place the client in Trendelenburg position
- C. Administer normal saline as prescribed
- D. Stop the dialysis and return blood
**Correct Answer: D – Stop the dialysis and return blood.**
**Rationale:**
- **Correct (D):** Hypotension during dialysis is an emergency. Stopping ultrafiltration and returning blood
prevents further fluid removal and stabilizes the client.
- **B:** Trendelenburg is no longer routinely recommended; supine with legs elevated may help, but
stopping dialysis is first.
- **C:** Saline may be given, but only after stopping ultrafiltration.
- **A:** Increasing flow rate would worsen hypotension.
---
**3.** The nurse is caring for a client after a cardiac catheterization via the radial artery. Which assessment
finding requires immediate action?
- A. Capillary refill of 2 seconds in the fingers
- B. Right hand is warm and pink
- C. The radial pulse is non-palpable by doppler
- D. Small hematoma (1 cm) at puncture site
,**Correct Answer: C – The radial pulse is non-palpable by doppler.**
**Rationale:**
- **Correct (C):** Loss of radial pulse indicates possible arterial occlusion or severe spasm – requires
immediate intervention.
- **A & B:** Normal findings.
- **D:** A small hematoma is common and can be monitored.
---
**4.** A client is receiving continuous renal replacement therapy (CRRT). The nurse notes that the filter
pressure is steadily increasing. What is the priority nursing action?
- A. Increase the anticoagulant infusion
- B. Assess the client for bleeding
- C. Document the finding as expected
- D. Notify the provider and prepare for filter change
**Correct Answer: D – Notify the provider and prepare for filter change.**
**Rationale:**
- **Correct (D):** Rising filter pressure indicates impending filter clotting. CRRT will stop working. The filter
will need to be changed.
- **A:** Increasing anticoagulant without order is unsafe.
- **B:** Bleeding assessment is important but not the priority for rising filter pressure.
- **C:** This is not expected; it signals filter failure.
---
**5.** The nurse is assisting with a lumbar puncture. After the procedure, the client develops a severe
headache when sitting upright that improves when lying down. Which intervention is most effective?
- A. Administer IV morphine
- B. Encourage vigorous hydration
- C. Have the client lie flat and increase caffeine intake
- D. Place the client in Trendelenburg position
**Correct Answer: C – Have the client lie flat and increase caffeine intake.**
**Rationale:**
- **Correct (C):** Post-LP headache is from CSF leakage. Flat position reduces traction on meninges; caffeine
constricts cerebral vessels and increases CSF pressure.
- **A:** Opioids are not first-line for this type of headache.
- **B:** Hydration helps, but caffeine is more specific.
- **D:** Trendelenburg is not indicated.
---
### Section 2: Perioperative Nursing (Questions 6–12)
**6.** A client is to receive general anesthesia for surgery. Which preoperative medication order should the
nurse question?
, - A. Metoclopramide (Reglan) 10 mg IV
- B. Famotidine (Pepcid) 20 mg IV
- C. Morphine sulfate 10 mg IV push over 2 minutes
- D. Cefazolin (Ancef) 1 g IV
**Correct Answer: C – Morphine sulfate 10 mg IV push over 2 minutes.**
**Rationale:**
- **Correct (C):** 10 mg morphine IV push is a high dose (usual 2-5 mg) and can cause severe respiratory
depression preoperatively.
- **A & B:** Given to reduce aspiration risk (prokinetic and H2 blocker).
- **D:** Prophylactic antibiotic is appropriate.
---
**7.** A client in the PACU has a blood pressure of 80/50 mm Hg, heart rate 110 bpm, and cool, clammy
skin. Which action should the nurse take first?
- A. Administer IV fluids as ordered
- B. Apply a warming blanket
- C. Check the surgical dressing for bleeding
- D. Notify the surgeon
**Correct Answer: A – Administer IV fluids as ordered.**
**Rationale:**
- **Correct (A):** The presentation suggests hypovolemia (likely from fluid shifts or bleeding). IV fluid bolus
is the immediate treatment.
- **C:** Checking the dressing is important but not first – you treat hypotension first.
- **D:** The surgeon may be notified after starting fluids.
- **B:** Warming blanket addresses hypothermia, not hypotension.
---
**8.** The nurse is teaching a client about deep breathing exercises after thoracic surgery. Which instruction
is correct?
- A. “Take rapid, shallow breaths to avoid pain.”
- B. “Inhale slowly, hold for 5 seconds, then exhale slowly.”
- C. “Breathe out as forcefully as possible into the spirometer.”
- D. “Perform these exercises only when you feel short of breath.”
**Correct Answer: B – Inhale slowly, hold for 5 seconds, then exhale slowly.**
**Rationale:**
- **Correct (B):** Sustained deep inhalation opens alveoli and prevents atelectasis.
- **A:** Shallow breathing promotes atelectasis.
- **C:** Exhalation is not the goal; sustained inhalation is.
- **D:** Exercises should be done regularly, not just when symptomatic.
---
Instructions:Choose the best answer. For select all that apply (SATA), select all
options that are correct.
**1.** The nurse is preparing a client for a lumbar puncture. The client asks, “Why do I have to curl up like a
ball?” Which response by the nurse is most accurate?
- A. “It helps keep you warm during the procedure.”
- B. “It opens the spaces between the vertebrae to insert the needle.”
- C. “It prevents you from moving during the procedure.”
- D. “It reduces the risk of bleeding after the puncture.”
**Correct Answer: B – It opens the spaces between the vertebrae to insert the needle.**
**Rationale:**
- **Correct (B):** Curling into a fetal position (or arching the back) maximizes the space between the spinous
processes, allowing easier access to the subarachnoid space.
- **A:** Position does not affect temperature regulation.
- **C:** The position helps access, but does not prevent movement; the client can still move.
- **D:** Bleeding risk is unaffected by position.
---
**2.** A client is undergoing hemodialysis and develops hypotension, nausea, and headache. The nurse
should take which action first?
- A. Increase the dialysate flow rate
- B. Place the client in Trendelenburg position
- C. Administer normal saline as prescribed
- D. Stop the dialysis and return blood
**Correct Answer: D – Stop the dialysis and return blood.**
**Rationale:**
- **Correct (D):** Hypotension during dialysis is an emergency. Stopping ultrafiltration and returning blood
prevents further fluid removal and stabilizes the client.
- **B:** Trendelenburg is no longer routinely recommended; supine with legs elevated may help, but
stopping dialysis is first.
- **C:** Saline may be given, but only after stopping ultrafiltration.
- **A:** Increasing flow rate would worsen hypotension.
---
**3.** The nurse is caring for a client after a cardiac catheterization via the radial artery. Which assessment
finding requires immediate action?
- A. Capillary refill of 2 seconds in the fingers
- B. Right hand is warm and pink
- C. The radial pulse is non-palpable by doppler
- D. Small hematoma (1 cm) at puncture site
,**Correct Answer: C – The radial pulse is non-palpable by doppler.**
**Rationale:**
- **Correct (C):** Loss of radial pulse indicates possible arterial occlusion or severe spasm – requires
immediate intervention.
- **A & B:** Normal findings.
- **D:** A small hematoma is common and can be monitored.
---
**4.** A client is receiving continuous renal replacement therapy (CRRT). The nurse notes that the filter
pressure is steadily increasing. What is the priority nursing action?
- A. Increase the anticoagulant infusion
- B. Assess the client for bleeding
- C. Document the finding as expected
- D. Notify the provider and prepare for filter change
**Correct Answer: D – Notify the provider and prepare for filter change.**
**Rationale:**
- **Correct (D):** Rising filter pressure indicates impending filter clotting. CRRT will stop working. The filter
will need to be changed.
- **A:** Increasing anticoagulant without order is unsafe.
- **B:** Bleeding assessment is important but not the priority for rising filter pressure.
- **C:** This is not expected; it signals filter failure.
---
**5.** The nurse is assisting with a lumbar puncture. After the procedure, the client develops a severe
headache when sitting upright that improves when lying down. Which intervention is most effective?
- A. Administer IV morphine
- B. Encourage vigorous hydration
- C. Have the client lie flat and increase caffeine intake
- D. Place the client in Trendelenburg position
**Correct Answer: C – Have the client lie flat and increase caffeine intake.**
**Rationale:**
- **Correct (C):** Post-LP headache is from CSF leakage. Flat position reduces traction on meninges; caffeine
constricts cerebral vessels and increases CSF pressure.
- **A:** Opioids are not first-line for this type of headache.
- **B:** Hydration helps, but caffeine is more specific.
- **D:** Trendelenburg is not indicated.
---
### Section 2: Perioperative Nursing (Questions 6–12)
**6.** A client is to receive general anesthesia for surgery. Which preoperative medication order should the
nurse question?
, - A. Metoclopramide (Reglan) 10 mg IV
- B. Famotidine (Pepcid) 20 mg IV
- C. Morphine sulfate 10 mg IV push over 2 minutes
- D. Cefazolin (Ancef) 1 g IV
**Correct Answer: C – Morphine sulfate 10 mg IV push over 2 minutes.**
**Rationale:**
- **Correct (C):** 10 mg morphine IV push is a high dose (usual 2-5 mg) and can cause severe respiratory
depression preoperatively.
- **A & B:** Given to reduce aspiration risk (prokinetic and H2 blocker).
- **D:** Prophylactic antibiotic is appropriate.
---
**7.** A client in the PACU has a blood pressure of 80/50 mm Hg, heart rate 110 bpm, and cool, clammy
skin. Which action should the nurse take first?
- A. Administer IV fluids as ordered
- B. Apply a warming blanket
- C. Check the surgical dressing for bleeding
- D. Notify the surgeon
**Correct Answer: A – Administer IV fluids as ordered.**
**Rationale:**
- **Correct (A):** The presentation suggests hypovolemia (likely from fluid shifts or bleeding). IV fluid bolus
is the immediate treatment.
- **C:** Checking the dressing is important but not first – you treat hypotension first.
- **D:** The surgeon may be notified after starting fluids.
- **B:** Warming blanket addresses hypothermia, not hypotension.
---
**8.** The nurse is teaching a client about deep breathing exercises after thoracic surgery. Which instruction
is correct?
- A. “Take rapid, shallow breaths to avoid pain.”
- B. “Inhale slowly, hold for 5 seconds, then exhale slowly.”
- C. “Breathe out as forcefully as possible into the spirometer.”
- D. “Perform these exercises only when you feel short of breath.”
**Correct Answer: B – Inhale slowly, hold for 5 seconds, then exhale slowly.**
**Rationale:**
- **Correct (B):** Sustained deep inhalation opens alveoli and prevents atelectasis.
- **A:** Shallow breathing promotes atelectasis.
- **C:** Exhalation is not the goal; sustained inhalation is.
- **D:** Exercises should be done regularly, not just when symptomatic.
---
