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NCLEX NCLEX-RN Exam
National Council Licensure Examination - NCLEX-RN (Page 26 )

Updated On: 12-Jan-2026
Page 26 of 345
PDF with 862 Questions

The nurse needs to be aware that the most common early complication of a myocardial infarction is:

  1. Diabetes mellitus
  2. Anaphylactic shock
  3. Cardiac hypertrophy
  4. Cardiac dysrhythmia

Answer(s): D

Explanation:

(A) Diabetes mellitus is not a common complication of myocardial infarction. (B) Anaphylactic shock is an allergic reaction. (C) Cardiac hypertrophy is a late potential complication. It is a common complication of congestive heart failure. (D) Myocardial infarction causes tissue damage, which may interrupt electrical impulses. Myocardial irritability results from lack of oxygenated tissue.



A client who has gout is most likely to form which type of renal calculi?

  1. Struvite stones
  2. Staghorn calculi
  3. Uric acid stones
  4. Calcium stones

Answer(s): C

Explanation:

(A) The presence of urinary tract infection is a factor in the formation of struvite stones. (B) Staghorn calculi is the other name for struvite stones associated with urinary tract infection. (C) Clients who have gout form uric acid stones. (D) Clients who have increased urinary excretion of calcium form calcium stones.



A client has returned to the unit following a left femoral popliteal bypass graft. Six hours later, his dorsalis pedis pulse cannot be palpated, and his foot is cool and dusky. The nurse should:

  1. Continue to monitor the foot
  2. Notify the physician immediately
  3. Reposition and reassess the foot
  4. Assure the client that his foot is fine

Answer(s): B

Explanation:

(A) The client is losing blood supply to his left foot. Continuing to monitor the foot will not help restore the blood supply to the foot. (B) The physician should be notified immediately because the client is losing blood supply to his left foot and is in danger of losing the foot and/or leg. (C) The presenting symptoms are of an emergency nature and require immediate intervention. (D) This action would be giving the client false assurance.



A client is going to have a pneumonectomy in the morning. She had a previous negative surgical experience, is talking rapidly, and has an increased pulse and respiratory rate. Nursing interventions for this client should include:

  1. Providing opportunities to ask questions and talk about concerns
  2. Providing distractors such as reading or watching television
  3. Telling her that she should not be so nervous and assuring her that everything will be OK
  4. Reminding her that this surgery is not as extensive as her past surgery was

Answer(s): A

Explanation:

(A) This intervention will help to clarify any misunderstandings about the surgery and give the client an opportunity to verbalize concerns about the surgery. (B) Distractors will not alleviate the preoperative anxiety that the client is experiencing. This response actually denies the client's anxiety. (C) This intervention is false assurance and denies that anxiety is a normal response to the threat of surgery. (D) Psychological responses are not directly related to the extent of the surgery, because they are influenced by the client's past experiences.



A client has returned to the unit from the recovery room after having a thyroidectomy. The nurse knows that a major complication after a thyroidectomy is:

  1. Respiratory obstruction
  2. Hypercalcemia
  3. Fistula formation
  4. Myxedema

Answer(s): A

Explanation:

(A) Respiratory obstruction due to edema of the glottis, bilateral laryngeal nerve damage, or tracheal compression from hemorrhage is a major complication after a thyroidectomy. (B) Hypocalcemia accompanied by tetany from accidental removal of one or more parathyroid glands is a major complication, not hypercalcemia. (C) Fistula formation is not a major complication associated with a thyroidectomy. It is a major complication with a laryngectomy.(D) Myxedema is hypothyroidism that occurs in adults and is not a complication of a thyroidectomy. A thyroidectomy client tends to develop thyroid storm, which is excess production of thyroid hormone.



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