NCLEX-RN
Basic Adult Health Care NCLEX Questions Questions
Extract:
Question 1 of 5
A client who has been diagnosed with bladder cancer is scheduled for an ileal conduit. Preoperatively, the nurse reinforces the client's understanding of the surgical procedure by explaining that an ileal conduit:
Correct Answer: C
Rationale: An ileal conduit diverts urine from the ureters to an abdominal stoma, where it is collected in an external pouch, a permanent procedure for bladder cancer management.
Question 2 of 5
A male client with a head injury regains consciousness and the normal loss. Which of the following nursing statements is most appropriate as the client awakens?
Correct Answer: D
Rationale: Providing clear, concise orientation information is most appropriate for a client regaining consciousness to reduce confusion and anxiety. Calling family, asking for personal details, or assuming confusion may overwhelm or distress the client.
Question 3 of 5
A 79-year-old female client is admitted to the hospital with a diagnosis of bacterial pneumonia. While obtaining the client's health history, the nurse learns that the client has osteoarthritis, follows a vegetarian diet, and is very concerned with cleanliness. Which of the following would most like to a predisposing factor for the diagnosis of pneumonia?
Correct Answer: A
Rationale: Advanced age weakens the immune system and respiratory muscles, increasing pneumonia risk. Osteoarthritis, a vegetarian diet, and daily bathing do not directly predispose to pneumonia.
Question 4 of 5
The unliscensed assistive personnel (UAP) reports to the registered nurse that a client admitted with pneumonia is very diaphoretic. The nurse reviews the following vital signs in the chart obtained by the UAP. The nurse should:
Correct Answer: B
Rationale: A client with pneumonia experiencing diaphoresis is at risk for dehydration. The fluid status, intake, and output should be monitored closely. The client is febrile, causing an increase in heart rate. Fluid volume defi cit may also increase the heart rate. A beta blocker is not indicated since the underlying cause of the tachycardia can be treated with acetaminophen (Tylenol) and fl uid volume. Bed rest limits lung expansion and sitting up and deep breathing should be encouraged in a client with pneumonia. The blood pressure is stable enough to allow the client to get out of bed to the chair, with assistance to ensure safety
Question 5 of 5
A client with disseminated intravascular coagulation develops ventricular microvascular thrombosis. The nurse should assess the client for:
Correct Answer: B
Rationale: Microvascular thrombosis in DIC can cause focal ischemia by obstructing small vessels, leading to tissue damage in organs like the kidneys or brain. Hemoptysis, petechiae, and hematuria are related to bleeding, not thrombosis.