NCLEX-RN
Adult Health II Respiratory NCLEX Questions Questions
Extract:
Question 1 of 5
A client is to be discharged from same-day surgery 7 hours after his inguinal hernia repair. Which of the following indicates this client is ready to be discharged?
Correct Answer: A
Rationale: Voiding 500 mL indicates normal bladder function, a key discharge criterion after hernia repair, ensuring no urinary retention from anesthesia or surgery.
Question 2 of 5
The nurse observes that a client's ileostomy output is green and watery. Which action should the nurse take first?
Correct Answer: B
Rationale: Green, watery output is normal for an ileostomy, especially early post-surgery, and should be documented. Notifying the physician, increasing fiber, or giving antidiarrheals are unnecessary unless other symptoms arise. CN: Physiological adaptation; CL: Synthesize
Question 3 of 5
A client with deep vein thrombosis (DVT) has an edematous right lower extremity. The client lies on her right side frequently. Rubor is noted on the lateral aspect of the right ankle. From the data collected, the appropriate nursing diagnosis for this client would be:
Correct Answer: D
Rationale: Edema, frequent lying on the right side, and rubor (redness) indicate pressure and poor circulation, increasing the risk for skin breakdown. Risk for impaired skin integrity is the most appropriate nursing diagnosis. Activity intolerance, ineffective health maintenance, and pain are less specific to the data.
Question 4 of 5
A client undergoes surgery to repair lung injuries. Postoperative orders include the transfusion of one unit of packed red blood cells at a rate of 60 mL/hour. How long would this transfusion take to infuse?
Correct Answer: B
Rationale: A unit of packed red blood cells is approximately 250–300 mL. At 60 mL/hour, 240 mL (close to a unit) takes 240 ÷ 60 = 4 hours.
Question 5 of 5
A client who has been diagnosed with peripheral vascular disease (PVD) is being discharged. The client needs further instruction if she says she will:
Correct Answer: D
Rationale: Using iodine on an injured site is incorrect, as it can be cytotoxic and impair wound healing in PVD, where tissue perfusion is already compromised. Avoiding heating pads (risk of burns), not crossing legs (improves circulation), and wearing leather shoes (protects feet) are appropriate self-care measures.