NCLEX-RN
Adult Health Med Surg NCLEX Test Bank Questions
Extract:
Question 1 of 5
A client is eligible for patient-controlled analgesia (PCA) when:
Correct Answer: C
Rationale: PCA requires the client to have the cognitive and physical ability to self-dose, ensuring safe and effective pain management.
Question 2 of 5
Which of the following client situations would require the most intensive nursing interventions for immobility?
Correct Answer: C
Rationale: A 75-year-old man with a pathologic femur fracture requires the most intensive nursing interventions for immobility due to pain, risk of further injury, and need for mobility aids and rehabilitation.
Question 3 of 5
The nurse is observing a student nurse administer eyedrops, as shown in the figure. What should the nurse instruct the student to do?
Correct Answer: C
Rationale: The student has positioned the dropper and the client correctly to prevent injury to the client's eye. The student should administer the drops in the center of the lower lid. Following administration of the eyedrops, the client should blink her eyes to distribute the medication; squeezing or rubbing her eyes might cause the medication to drip out of the eye.
Question 4 of 5
A health care provider orders 0.5 mg of protamine sulfate for a client who is showing signs of bleeding after receiving a 100-unit dose of heparin. The nurse should expect the effects of the protamine sulfate to be noted in which of the following time frames?
Correct Answer: C
Rationale: Protamine sulfate neutralizes heparin rapidly, with effects typically seen within 20 minutes of administration. This allows for quick reversal of heparin's anticoagulant effects in cases of bleeding. The other time frames are either too short or too long.
Question 5 of 5
A client has an epidural catheter inserted for postoperative pain management. The client rates his pain at 4 on a 0-to-5 pain scale. What should the nurse do first?
Correct Answer: C
Rationale: Assessing vital signs first ensures the client is stable, as a pain level of 4 may indicate complications (e.g., respiratory depression). Checking the pump, adjusting the catheter, or notifying the physician follow if needed.