NCLEX-RN
Adult Health Med Surg NCLEX Test Bank Questions
Extract:
Question 1 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 2 of 5
In the early postoperative period after a bilateral adrenalectomy, the client has an increased temperature. The nurse should assess the client further for signs of:
Correct Answer: C
Rationale: An increased temperature post-adrenalectomy suggests wound infection, a common postoperative complication requiring prompt assessment.
Question 3 of 5
A client is beginning external beam radiation therapy to the right axilla after a lumpectomy for breast cancer. Which of the following should the nurse include in client teaching?
Correct Answer: C
Rationale: Applying deodorant only under the left arm avoids irritation to the radiated right axilla, which is sensitive and prone to skin reactions during treatment.
Question 4 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 5 of 5
A client with multiple sclerosis (MS) is experiencing bowel incontinence and is starting a bowel retraining program. Which strategy is inappropriate?
Correct Answer: D
Rationale: Limiting fluid intake to 1,000 mL/day is inappropriate, as adequate hydration is needed for bowel function. High-fiber diet, regular elimination times, and elevated toilet seats support bowel retraining.