NCLEX-RN
Adult Health Med Surg NCLEX Test Bank Questions
Extract:
Question 1 of 5
A client is being treated for deep vein thrombosis (DVT) in the left femoral artery. The physician has ordered 60 mg of enoxaparin (Lovenox) subcutaneously. Before administering the drug, the nurse checks the client's laboratory results, noted below. Based on these results, the nurse should:
Correct Answer: C
Rationale: Without specific lab results provided, the context implies abnormal values (e.g., low platelets or high INR) that increase bleeding risk with enoxaparin, a low-molecular-weight heparin. The nurse should inform the physician to evaluate the results before proceeding. Administering or withholding without consultation is unsafe, and assessing for bleeding is not the immediate action.
Question 2 of 5
The primary goal for the client with Buerger's disease is to prevent:
Correct Answer: D
Rationale: The primary goal in Buerger's disease is to prevent gangrene, as the condition causes severe arterial and venous inflammation, leading to occlusion and tissue ischemia. Smoking cessation and vasodilation are key to avoiding tissue necrosis. Embolus, fat embolus, or thrombophlebitis are less specific concerns.
Question 3 of 5
The client who had an open femoral fracture was discharged to her home where she developed fever, night sweats, chills, restlessness, and restrictive movement of the fractured leg. Which of the following reflects the best interpretation of these findings?
Correct Answer: B
Rationale: These symptoms suggest osteomyelitis, a bone infection common after open fractures.
Question 4 of 5
What is the nurse's priority when a client experiences a seizure?
Correct Answer: B
Rationale: Protecting the airway is the priority to ensure oxygenation during a seizure.
Question 5 of 5
The nurse is assessing a client for movement after halo traction placement for a C8 fracture. The nurse should document which of the following?
Correct Answer: A
Rationale: A C8 fracture affects the lower cervical nerves, but shoulder shrug (trapezius, innervated by cranial nerve XI and C3-C4) should remain intact. Arm movements and hand grasp involve C5-C8 and may be impaired, making shoulder shrug the most reliable intact movement to document.