🎯 High-Yield Points for This Topic
- Priority is always ABC (Airway, Breathing, Circulation) then safety
- Post-operative: assess airway first, then vitals, then pain, then wound
- Positioning: after craniotomy raise HOB 30°; after thyroidectomy semi-Fowler
- Pre-op teaching: deep breathing, splinting incision, early ambulation
- Always think: which patient is most unstable or most at risk right now?
[Infographic: Med-Surg NCLEX Questions Key Concepts — Clinical Manifestations, Nursing Interventions, Priority Actions]
Practice Questions
Question 1
A nurse has four post-operative clients. Which client should be assessed FIRST?
✓ Correct: Client 6 hours post-thyroidectomy reporting neck tightness and difficulty swallowing
Neck tightness and difficulty swallowing post-thyroidectomy signals potential airway compromise from haematoma formation or laryngeal oedema — this is a surgical emergency. The nurse must assess immediately. Post-thyroidectomy haematoma can rapidly compress the trachea and cause complete airway obstruction. Fever in day-2 post-op is concerning but not immediately life-threatening.
Neck tightness and difficulty swallowing post-thyroidectomy signals potential airway compromise from haematoma formation or laryngeal oedema — this is a surgical emergency. The nurse must assess immediately. Post-thyroidectomy haematoma can rapidly compress the trachea and cause complete airway obstruction. Fever in day-2 post-op is concerning but not immediately life-threatening.
Question 2
A client with a new colostomy expresses distress about the appliance. What is the BEST initial nursing response?
✓ Correct: Encourage the client to look at the stoma and express their feelings
The best initial response is to encourage expression of feelings and use therapeutic communication. Body image disturbance and emotional adjustment are primary concerns with a new colostomy. Therapeutic communication establishes trust and allows the client to voice concerns before education begins. Rushing to education before emotional acknowledgment is counterproductive.
The best initial response is to encourage expression of feelings and use therapeutic communication. Body image disturbance and emotional adjustment are primary concerns with a new colostomy. Therapeutic communication establishes trust and allows the client to voice concerns before education begins. Rushing to education before emotional acknowledgment is counterproductive.
Question 3
A nurse is caring for a client with acute pancreatitis. Which intervention is the PRIORITY?
✓ Correct: Maintain NPO status and administer IV fluids as ordered
Acute pancreatitis management centres on bowel rest (NPO) to reduce pancreatic enzyme stimulation and IV fluid resuscitation. The inflamed pancreas must be rested completely — nothing by mouth. IV fluids prevent dehydration and hypotension from third-spacing. The prone position is not used; semi-Fowler or side-lying knee-chest position provides pain relief.
Acute pancreatitis management centres on bowel rest (NPO) to reduce pancreatic enzyme stimulation and IV fluid resuscitation. The inflamed pancreas must be rested completely — nothing by mouth. IV fluids prevent dehydration and hypotension from third-spacing. The prone position is not used; semi-Fowler or side-lying knee-chest position provides pain relief.
Question 4
A client with renal failure has a potassium level of 6.2 mEq/L. Which finding requires IMMEDIATE intervention?
✓ Correct: Peaked T waves on ECG
Peaked T waves on ECG are the earliest and most critical sign of hyperkalaemia-related cardiac toxicity. A potassium of 6.2 mEq/L with peaked T waves indicates the heart is at risk for fatal arrhythmias (ventricular fibrillation). This requires immediate intervention: calcium gluconate to stabilise cardiac membranes, followed by glucose/insulin and kayexalate. The other findings are concerning but do not signal imminent cardiac emergency.
Peaked T waves on ECG are the earliest and most critical sign of hyperkalaemia-related cardiac toxicity. A potassium of 6.2 mEq/L with peaked T waves indicates the heart is at risk for fatal arrhythmias (ventricular fibrillation). This requires immediate intervention: calcium gluconate to stabilise cardiac membranes, followed by glucose/insulin and kayexalate. The other findings are concerning but do not signal imminent cardiac emergency.
Question 5
A post-operative client is confused and agitated. Which assessment does the nurse perform FIRST?
✓ Correct: Check oxygen saturation and respiratory status
Post-operative confusion and agitation are commonly caused by hypoxaemia. The nurse should assess oxygen saturation and respiratory status first because hypoxia is immediately life-threatening and easily correctable. Pain, medication effects, and neurological causes are assessed subsequently. This follows the ABCDE assessment priority framework.
Post-operative confusion and agitation are commonly caused by hypoxaemia. The nurse should assess oxygen saturation and respiratory status first because hypoxia is immediately life-threatening and easily correctable. Pain, medication effects, and neurological causes are assessed subsequently. This follows the ABCDE assessment priority framework.
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[Clinical Concept Map: Med-Surg NCLEX Questions — Pathophysiology, Assessment Findings, Nursing Actions]