NCLEX-RN
Adult Health Med Surg NCLEX Test Bank Questions
Extract:
Question 1 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 2 of 5
The nurse is assessing a client for movement after halo traction placement for a C8 fracture. The nurse should document which of the following?
Correct Answer: A
Rationale: A C8 fracture affects the lower cervical nerves, but shoulder shrug (trapezius, innervated by cranial nerve XI and C3-C4) should remain intact. Arm movements and hand grasp involve C5-C8 and may be impaired, making shoulder shrug the most reliable intact movement to document.
Question 3 of 5
Which of the following findings is the best indication that fluid replacement for the client in hypovolemic shock is adequate?
Correct Answer: A
Rationale: Adequate fluid replacement in hypovolemic shock is best indicated by a urine output greater than 30 mL/hour, reflecting restored renal perfusion. Blood pressure and respiratory rate improvements are supportive but less specific.
Question 4 of 5
A client who has a history of an inguinal hernia is admitted to the hospital with sudden, severe abdominal pain, vomiting, and abdominal distention. The nurse should assess the client further for which of the following complications?
Correct Answer: C
Rationale: Sudden, severe abdominal pain, vomiting, and distention in a client with an inguinal hernia suggest a strangulated hernia, where the herniated tissue loses blood supply, requiring urgent assessment. Peritonitis, incarceration, or perforation are less likely without additional signs. CN: Physiological adaptation; CL: Analyze
Question 5 of 5
A client with terminal cancer expresses fear of dying alone. The nurse's most therapeutic response is:
Correct Answer: A
Rationale: Assuring the client that someone will be present addresses their fear directly, providing emotional reassurance and support.