NCLEX-RN
Adult Health II Respiratory NCLEX Questions Questions
Extract:
Question 1 of 5
A client underwent surgery to repair an abdominal aortic aneurysm. The surgeon made an incision that extends from the xiphoid process to the pubis. At 12 noon 2 days after surgery, the client complains of abdominal distention. The nurse checks the progress notes in the medical record, as shown below. What is most likely contributing to the client's abdominal distention?
Correct Answer: B
Rationale: Abdominal distention 2 days post-AAA repair is most likely due to paralytic ileus, a common postoperative complication from bowel manipulation and anesthesia, causing slowed gut motility. Bowel obstruction, peritonitis, or wound dehiscence would present with additional symptoms (e.g., fever, vomiting, or wound disruption).
Question 2 of 5
Which of the following clients is at greatest risk for Buerger's disease?
Correct Answer: A
Rationale: Buerger's disease (thromboangiitis obliterans) is strongly associated with heavy tobacco use, particularly in young males. A 29-year-old male with a 14-year smoking history is at greatest risk. Birth control pills, diabetes, and atherosclerosis are not primary risk factors for Buerger's disease.
Question 3 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.
Question 4 of 5
The nurse assesses the client's stoma during the initial postoperative period. Which of the following observations should be reported immediately to the physician?
Correct Answer: B
Rationale: A dark red to purple stoma indicates inadequate blood supply, which is a medical emergency requiring immediate reporting to the physician. Slight edema is expected post-surgery, a small amount of blood oozing is normal, and lack of stool expulsion in the initial period may not be immediately concerning unless other symptoms are present. CN: Physiological adaptation; CL: Analyze
Question 5 of 5
A 60-year-old female is diagnosed with hypothyroidism. The nurse should assess the client for which of the following?
Correct Answer: B
Rationale: Hypothyroidism causes a slowed metabolism, leading to weight gain. Tachycardia, diarrhea, and nausea are more associated with hyperthyroidism.