NCLEX-RN
Adult Health Med Surg NCLEX Test Bank Questions
Question 1 of 5
The nurse is assessing a client who has had a myocardial infarction (MI). The nurse notes the cardiac rhythm shown on the electrocardiogram strip below. The nurse identifies this rhythm as which of the following?
Correct Answer: N/A
Rationale: Without the ECG strip, the rhythm cannot be identified. This question is incomplete in the provided document.
Question 2 of 5
After the administration of t-PA, the assessment priority is to:
Correct Answer: A
Rationale: Monitoring for chest pain post-t-PA assesses for reperfusion success or reocclusion, a priority to ensure effective thrombolysis and myocardial perfusion.
Question 3 of 5
A client has a throbbing headache when nitroglycerin is taken for angina. The nurse should instruct the client that:
Correct Answer: A
Rationale: Headache is a common side effect of nitroglycerin due to vasodilation. Acetaminophen or ibuprofen can safely relieve it without discontinuing the medication.
Question 4 of 5
A client has returned from the cardiac catheterization laboratory after a balloon valvuloplasty for mitral stenosis. Which of the following requires immediate nursing action?
Correct Answer: C
Rationale: Increased somnolence may indicate neurological complications (e.g., stroke) post-valvuloplasty, requiring immediate action. Other findings are less urgent.
Question 5 of 5
A client's job involves working in a warm, dry room, frequently bending and crouching to check the underside of a high-speed press, and wearing eye guards. Given this information, the nurse should assess the client for which of the following?
Correct Answer: D
Rationale: Frequent bending and crouching in a warm, dry environment increases the risk of orthostatic hypotension due to dehydration and positional changes.