NCLEX-RN
Basic Adult Health Care NCLEX Questions Questions
Extract:
Question 1 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.
Question 2 of 5
A client states, 'I don't want any more tests. Who cares what kind of leukemia I have? I just want to be treated now.' Which is the nurse's best response?
Correct Answer: B
Rationale: The nurse should explain that specific tests help tailor treatment to the type of leukemia, improving effectiveness. This addresses the client's desire for treatment while emphasizing the importance of diagnostic clarity. The other responses are empathetic but do not provide a rationale for testing.
Question 3 of 5
A client with a suspected diagnosis of Hodgkin's disease is to have a lymph node biopsy. Which action is correct for handling the lymph node biopsy specimen for histologic examination for this client?
Correct Answer: C
Rationale: The lymph node biopsy specimen should be placed in a container and sent to the laboratory promptly to preserve tissue integrity for histologic examination. Sterile technique is maintained during the procedure, not for handling afterward, and masks/gowns or technician assistance are not required for transport.
Question 4 of 5
Which is a priority assessment for the client in shock who is receiving an I.V. infusion of packed red blood cells and normal saline solution?
Correct Answer: B
Rationale: During a blood transfusion in a client in shock, the priority assessment is for an anaphylactic reaction, as transfusion reactions can be life-threatening and require immediate intervention. Fluid balance, pain, and consciousness are monitored but are secondary.
Question 5 of 5
Which of the following would be an expected outcome for a client recovering from an upper respiratory tract infection? The client will:
Correct Answer: D
Rationale: An expected outcome for recovery from an upper respiratory tract infection is reduced nasal obstruction and discharge, indicating resolution of inflammation and infection. A fluid intake of 800 mL is too low; 1,500–2,000 mL is more appropriate. Chills are not a typical measure of recovery. Productive coughing without discomfort may occur but is less specific than reduced nasal symptoms.