NCLEX-RN
Adult Health Med Surg NCLEX Test Bank Questions
Extract:
Question 1 of 5
A client receiving TPN reports sudden chest pain and dyspnea. Which action should the nurse take first?
Correct Answer: C
Rationale: Sudden chest pain and dyspnea in a client receiving TPN may indicate a serious complication like an air embolism or infection, requiring immediate physician notification. Stopping the infusion or checking glucose is premature, and oxygen requires an order. CN: Physiological adaptation; CL: Synthesize
Question 2 of 5
One month following a subtotal gastrectomy for cancer, the nurse is evaluating the nursing care goal related to nutrition. Which of the following indicates that the client has attained the goal? The client has:
Correct Answer: D
Rationale: Achieving optimal nutritional status, whether through oral or parenteral feedings, is the primary goal one month post-gastrectomy, as it indicates the client is meeting nutritional needs.
Question 3 of 5
A client who had a gastrectomy has been in the postanesthesia recovery room for 30 minutes when his vital signs suddenly change. In addition to notifying the physician, what other action should the nurse take immediately?
Correct Answer: A
Rationale: Sudden vital sign changes post-gastrectomy suggest hypoxia or shock. Administering oxygen addresses potential respiratory compromise, a common postoperative issue, while awaiting physician guidance.
Question 4 of 5
A client with bladder cancer receives intravesical chemotherapy. The nurse should:
Correct Answer: A
Rationale: Hematuria is a potential side effect of intravesical chemotherapy, requiring monitoring.
Question 5 of 5
What is a priority nursing action for a client post-ileal conduit surgery?
Correct Answer: A
Rationale: Monitoring stoma color ensures viability; a pink/red stoma indicates good blood supply.