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: D
Rationale: Based on the laboratory fi ndings, prothrombin time and INR are at acceptable anticoagulation levels for the treatment of DVT. However, the platelets are below the acceptable level. Clients taking enoxaparin are at risk for thrombocytopenia. Because of the low platelet level, the nurse should withhold the enoxaparin, assess the client for bleeding, and then contact the physician.
Question 2 of 5
A client is being discharged with nasal packing in place. The nurse should instruct the client to:
Correct Answer: A
Rationale: Frequent mouth care prevents dryness and infection due to mouth breathing with nasal packing. Saline drops are not needed with packing in place. The third option is unclear. Gargling is not routinely required.
Question 3 of 5
A 36-year-old male with lymphoma is assessing a client who reports distress 9 days after chemotherapy. Because of the risk for septic shock, the nurse should assess the client for which cluster of symptoms?
Correct Answer: C
Rationale: Elevated temperature, oliguria, and hypotension are critical signs of septic shock, a life-threatening complication in chemotherapy patients due to neutropenia.
Question 4 of 5
The physician orders intestinal decompression with a Cantor tube for a client with an intestinal obstruction. In order to determine effectiveness of intestinal decompression the nurse should evaluate the client to determine if:
Correct Answer: A
Rationale: The effectiveness of a Cantor tube is determined by the removal of fluid and gas from the intestine, relieving the obstruction. Bowel movements, urinary output, or sitting up without pain are not direct indicators of decompression success. CN: Physiological adaptation; CL: Evaluate
Question 5 of 5
The nurse's best explanation for why the severely neutropenic client is placed in reverse isolation is that reverse isolation helps prevent the spread of organisms:
Correct Answer: A
Rationale: Reverse isolation protects severely neutropenic clients by preventing the introduction of pathogens from external sources, such as staff, visitors, or equipment. It is not about preventing spread from the client or specific disposal/handling techniques.