NCLEX-RN
Basic Adult Health Care NCLEX Questions 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
A client has been in an automobile accident and the nurse is assessing the client for possible pneumothorax. The nurse should assess the client for:
Correct Answer: A
Rationale: Sudden, sharp chest pain is a hallmark of pneumothorax due to pleural irritation. Wheezing, hemoptysis, and cyanosis are less specific or occur later.
Question 3 of 5
A client with a suspected diagnosis of Hodgkin's disease is to have a lymph node biopsy. Which action is correct for handling the lymph node biopsy specimen for histologic examination for this client?
Correct Answer: C
Rationale: The lymph node biopsy specimen should be placed in a container and sent to the laboratory promptly to preserve tissue integrity for histologic examination. Sterile technique is maintained during the procedure, not for handling afterward, and masks/gowns or technician assistance are not required for transport.
Question 4 of 5
A client with a hip fracture is receiving heparin to prevent thromboembolism. Which laboratory value should the nurse monitor?
Correct Answer: B
Rationale: Heparin's effect is monitored via aPTT to ensure therapeutic anticoagulation.
Question 5 of 5
A nursing assistant is providing care to a client with left-sided paralysis. Which of the following actions by the nursing assistant requires the nurse to provide further instruction?
Correct Answer: C
Rationale: Pulling under the paralyzed shoulder can cause injury or discomfort. Passive ROM, elevating the bed, and high-top shoes are appropriate for paralysis care.