NCLEX-RN
Adult Health Med Surg NCLEX Test Bank Questions
Extract:
Question 1 of 5
A client with type 1 diabetes mellitus has influenza. The nurse should instruct the client to:
Correct Answer: A
Rationale: Influenza can increase blood glucose levels due to stress and illness, requiring more frequent monitoring to adjust insulin doses.
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
The nurse is preparing the client for cardioversion. The nurse should do which of the following? Select all that apply.
Correct Answer: A,C,D,E
Rationale: Using a conducting agent (
A), calling 'clear' (
C), recording energy/rhythm (
D), and applying pressure (E) ensure safe and effective cardioversion. Paddles over clothing is incorrect.
Question 4 of 5
When comparing the hematocrit levels of a postoperative client, the nurse notes that the hematocrit decreased from 36% to 34% on the third day even though the RBC count and hemoglobin value remained within 10 mg/dL and 11.9 g/dL, respectively. The nurse should:
Correct Answer: C
Rationale: A slight decrease in hematocrit (36% to 34%) on postoperative day 3, with stable RBC count and hemoglobin, is likely due to hemodilution from fluid administration rather than active bleeding. The nurse should continue to monitor vital signs and hematologic parameters. Checking for bleeding is unnecessary without signs of hemorrhage, calling the physician is premature, and oxygen is not indicated.
Question 5 of 5
A client is beginning external beam radiation therapy to the right axilla after a lumpectomy for breast cancer. Which of the following should the nurse include in client teaching?
Correct Answer: C
Rationale: Applying deodorant only under the left arm avoids irritation to the radiated right axilla, which is sensitive and prone to skin reactions during treatment.