NCLEX-RN
NCLEX RN Physiological Adaptation Questions
Extract:
Question 1 of 4
A client is 2 hours post-op for a right total knee replacement. Upon assessment by the nurse, which information requires notification of the doctor?
Correct Answer: A
Rationale: Hemoglobin of 10.2 g/L (
A) indicates significant blood loss requiring notification. Minor bleeding (
B), low-grade fever (
C), and expected pain (
D) are less urgent.
Question 2 of 4
Which of the following is not a recommended preparation for electroconvulsive therapy (ECT)?
Correct Answer: D
Rationale: Anticonvulsants (
D) are not given before ECT, as seizures are therapeutic. Anticholinergics (
A), NPO/bath (
B), and consent (
C) are standard preparations.
Question 3 of 4
The nurse is caring for a client with left-sided heart failure. Which assessment findings does the nurse anticipate for this client? Select all that apply.
Correct Answer: A,C,F
Rationale: Left-sided heart failure causes pulmonary congestion, leading to dyspnea (
A), dependent edema (
C), and crackles/wheezes (F). Spleen engorgement (
B), jugular vein distention (
D), and weak pulses (E) are more typical of right-sided failure.
Question 4 of 4
The nurse is caring for a client who is HIV-positive. The nurse understands which of the following to be true regarding HIV and AIDS?
Correct Answer: A
Rationale: Viral load testing (
A) monitors HIV progression and treatment efficacy. Western blot requires two antigens (
B), AIDS involves low CD4 counts, not WBC (
C), and ELISA detects antibodies after 3-12 weeks (
D).
Question 5 of 4
The nurse is performing the Glasgow coma scale on a client. The assessment is as follows: eye opening, to pain; motor response, localizes pain; verbal response, inappropriate words. The nurse interprets which score is correct for this client?
Correct Answer: A
Rationale: Glasgow Coma Scale: Eye opening to pain = 2, localizes pain = 5, inappropriate words = 2.
Total = 2 + 5 + 2 = 9 (
A).