# NCLEX Medical-Surgical Nursing Examination
## Form: MS-NCLEX-005 | | Time Limit: 90 Minutes
**Instructions:** Select the best answer. For Select All That Apply (SATA), choose all correct options.
Assume a stable adult client unless otherwise indicated.
**1.** A client is scheduled for a lumbar puncture. The nurse explains the procedure to the client.
Which statement by the client indicates understanding?
- A. "I will need to lie flat for several hours after the procedure."
- B. "I can eat a full meal right before the procedure."
- C. "The needle will be inserted into my spinal cord."
- D. "I will be asleep during the entire procedure."
**Correct Answer: A – "I will need to lie flat for several hours after the procedure."**
**Rationale:**
- **Correct (A):** Lying flat for 1-2 hours (or longer per provider order) helps prevent post-lumbar
puncture headache by reducing CSF leakage.
- **B:** NPO status is typically required for several hours before the procedure.
- **C:** The needle is inserted into the subarachnoid space, not into the spinal cord itself.
**2.** The nurse is caring for a client immediately after a cardiac catheterization via the right femoral
artery. The client reports feeling "wet" in the groin area. What is the nurse's priority action?
- A. Remove the dressing to inspect the site
- B. Apply firm pressure above the puncture site
- C. Assess the groin for visible bleeding
- D. Document the finding as expected
**Correct Answer: C – Assess the groin for visible bleeding**
**Rationale:**
,- **Correct (C):** The client's report of feeling "wet" suggests possible bleeding. The nurse should first
visualize the site to confirm bleeding.
- **B:** Pressure may be needed but only after confirming bleeding.
- **A:** Removing the dressing may dislodge a clot; the nurse should look for bleeding through the
dressing first.
- **D:** Bleeding is not expected; this requires action.
**3.** A client is receiving hemodialysis through an arteriovenous (AV) graft in the left arm. Which
nursing action is appropriate? *(Select all that apply)*
- A. Auscultate the graft for a bruit every shift
- B. Palpate the graft for a thrill
- C. Obtain blood pressure from the left arm
- D. Apply tight clothing over the graft site
- E. Check distal pulses in the left hand
**Correct Answers: A, B, E**
**Rationale:**
- **A & B:** A bruit (audible) and thrill (palpable) indicate patency of the graft.
- **E:** Distal pulses should be assessed to ensure adequate perfusion.
- **C:** Never take blood pressure on the arm with a vascular access – this can damage the graft.
- **D:** Tight clothing can compress the graft and impair blood flow.
**4.** A client on continuous renal replacement therapy (CRRT) has a venous pressure alarm sounding
"high." Which action should the nurse take first?
- A. Increase the blood flow rate
- B. Check for kinks in the venous return line
- C. Administer a fluid bolus
- D. Replace the entire circuit
**Correct Answer: B – Check for kinks in the venous return line**
, **Rationale:**
- **Correct (B):** High venous pressure often indicates an obstruction between the filter and the
patient (kinked tubing, closed clamp, or patient position). Checking for kinks is the first and simplest
intervention.
- **A:** Increasing blood flow would worsen high pressure.
- **C:** A fluid bolus does not address the pressure alarm.
- **D:** Replacing the circuit is premature without troubleshooting.
---
**5.** The nurse is preparing a client for a transesophageal echocardiogram (TEE). Which statement by
the client requires immediate action?
- A. "I have a history of high blood pressure."
- B. "I took my metformin this morning."
- C. "I haven't eaten anything since last night."
- D. "I am allergic to lidocaine."
**Correct Answer: D – "I am allergic to lidocaine."**
**Rationale:**
- **Correct (D):** Lidocaine is used to anesthetize the throat during TEE. An allergy requires alternative
anesthesia and notification of the provider.
- **A:** Hypertension is not a contraindication.
- **B:** Metformin is often held before procedures but not an emergency.
- **C:** NPO status is correct.
---
### Section 2: Perioperative Nursing (Questions 6–12)
## Form: MS-NCLEX-005 | | Time Limit: 90 Minutes
**Instructions:** Select the best answer. For Select All That Apply (SATA), choose all correct options.
Assume a stable adult client unless otherwise indicated.
**1.** A client is scheduled for a lumbar puncture. The nurse explains the procedure to the client.
Which statement by the client indicates understanding?
- A. "I will need to lie flat for several hours after the procedure."
- B. "I can eat a full meal right before the procedure."
- C. "The needle will be inserted into my spinal cord."
- D. "I will be asleep during the entire procedure."
**Correct Answer: A – "I will need to lie flat for several hours after the procedure."**
**Rationale:**
- **Correct (A):** Lying flat for 1-2 hours (or longer per provider order) helps prevent post-lumbar
puncture headache by reducing CSF leakage.
- **B:** NPO status is typically required for several hours before the procedure.
- **C:** The needle is inserted into the subarachnoid space, not into the spinal cord itself.
**2.** The nurse is caring for a client immediately after a cardiac catheterization via the right femoral
artery. The client reports feeling "wet" in the groin area. What is the nurse's priority action?
- A. Remove the dressing to inspect the site
- B. Apply firm pressure above the puncture site
- C. Assess the groin for visible bleeding
- D. Document the finding as expected
**Correct Answer: C – Assess the groin for visible bleeding**
**Rationale:**
,- **Correct (C):** The client's report of feeling "wet" suggests possible bleeding. The nurse should first
visualize the site to confirm bleeding.
- **B:** Pressure may be needed but only after confirming bleeding.
- **A:** Removing the dressing may dislodge a clot; the nurse should look for bleeding through the
dressing first.
- **D:** Bleeding is not expected; this requires action.
**3.** A client is receiving hemodialysis through an arteriovenous (AV) graft in the left arm. Which
nursing action is appropriate? *(Select all that apply)*
- A. Auscultate the graft for a bruit every shift
- B. Palpate the graft for a thrill
- C. Obtain blood pressure from the left arm
- D. Apply tight clothing over the graft site
- E. Check distal pulses in the left hand
**Correct Answers: A, B, E**
**Rationale:**
- **A & B:** A bruit (audible) and thrill (palpable) indicate patency of the graft.
- **E:** Distal pulses should be assessed to ensure adequate perfusion.
- **C:** Never take blood pressure on the arm with a vascular access – this can damage the graft.
- **D:** Tight clothing can compress the graft and impair blood flow.
**4.** A client on continuous renal replacement therapy (CRRT) has a venous pressure alarm sounding
"high." Which action should the nurse take first?
- A. Increase the blood flow rate
- B. Check for kinks in the venous return line
- C. Administer a fluid bolus
- D. Replace the entire circuit
**Correct Answer: B – Check for kinks in the venous return line**
, **Rationale:**
- **Correct (B):** High venous pressure often indicates an obstruction between the filter and the
patient (kinked tubing, closed clamp, or patient position). Checking for kinks is the first and simplest
intervention.
- **A:** Increasing blood flow would worsen high pressure.
- **C:** A fluid bolus does not address the pressure alarm.
- **D:** Replacing the circuit is premature without troubleshooting.
---
**5.** The nurse is preparing a client for a transesophageal echocardiogram (TEE). Which statement by
the client requires immediate action?
- A. "I have a history of high blood pressure."
- B. "I took my metformin this morning."
- C. "I haven't eaten anything since last night."
- D. "I am allergic to lidocaine."
**Correct Answer: D – "I am allergic to lidocaine."**
**Rationale:**
- **Correct (D):** Lidocaine is used to anesthetize the throat during TEE. An allergy requires alternative
anesthesia and notification of the provider.
- **A:** Hypertension is not a contraindication.
- **B:** Metformin is often held before procedures but not an emergency.
- **C:** NPO status is correct.
---
### Section 2: Perioperative Nursing (Questions 6–12)
