NCLEX-RN
Adult Health Med Surg NCLEX Test Bank Questions
Extract:
Question 1 of 5
A client has an epidural catheter inserted for postoperative pain management. The client rates his pain at 4 on a 0-to-5 pain scale. What should the nurse do first?
Correct Answer: C
Rationale: Assessing vital signs first ensures the client is stable, as a pain level of 4 may indicate complications (e.g., respiratory depression). Checking the pump, adjusting the catheter, or notifying the physician follow if needed.
Question 2 of 5
A client with peripheral vascular disease has bypass surgery. The primary goal of the plan of care after surgery is to:
Correct Answer: A
Rationale: The primary goal post-bypass surgery for PVD is to maintain circulation, ensuring graft patency and adequate blood flow to the extremity to prevent ischemia or graft failure. Infection prevention, pain relief, and education are important but secondary to circulation.
Question 3 of 5
A client has been admitted with acute renal failure. What should the nurse do? Select all that apply.
Correct Answer: B,C,D
Rationale: Taking vital signs, establishing IV access, and contacting the physician are immediate actions to assess and stabilize the client with acute renal failure.
Question 4 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 5 of 5
The nurse is observing a student nurse administer eyedrops, as shown in the figure. What should the nurse instruct the student to do?
Correct Answer: C
Rationale: The student has positioned the dropper and the client correctly to prevent injury to the client's eye. The student should administer the drops in the center of the lower lid. Following administration of the eyedrops, the client should blink her eyes to distribute the medication; squeezing or rubbing her eyes might cause the medication to drip out of the eye.