NCLEX-RN
Basic Adult Health Care NCLEX Questions Questions
Extract:
Question 1 of 5
A nurse is assessing a surgical client's blood pressure 8 hours after surgery. The client's blood pressure before surgery was 120/80 mm Hg and on admission to the postsurgical nursing unit, it was 110/80 mm Hg. The client's blood pressure is now 90/70 mm Hg. What should the nurse do first?
Correct Answer: B
Rationale: A drop to 90/70 mm Hg suggests hypovolemia, likely from bleeding. Checking the dressing for bleeding is the first step to identify the cause before further interventions.
Question 2 of 5
Following a laryngectomy, the nurse notices that the client has saliva collecting beneath the skin flaps. This finding is indicative of which of the following?
Correct Answer: D
Rationale: Saliva collecting beneath skin flaps post-laryngectomy indicates a fistula, where saliva leaks from the pharynx or esophagus into surrounding tissues, requiring immediate attention.
Question 3 of 5
A client with end-stage cancer is receiving morphine for pain. The family is concerned about addiction. The nurse should explain that:
Correct Answer: A
Rationale: In terminal illness, addiction is not a concern, as the priority is pain control to ensure comfort, and this explanation reassures the family.
Question 4 of 5
A client is scheduled to undergo right axillary-to-axillary artery bypass surgery. Which of the following interventions is most important for the nurse to implement in the preoperative period?
Correct Answer: D
Rationale: Avoiding venipuncture in the affected arm is critical preoperatively to preserve vascular integrity and prevent complications (e.g., hematoma) that could affect the axillary-to-axillary bypass surgery. Monitoring pulses, assessing temperature, and protecting from cold are important but less urgent than preventing vascular trauma.
Question 5 of 5
A client has a platelet count of 31,000/µL. The nurse should instruct the client to:
Correct Answer: A
Rationale: A platelet count of 31,000/µL indicates thrombocytopenia, increasing the risk of bleeding from minor trauma. Padding sharp surfaces helps prevent injuries that could lead to bleeding. Assessing for petechiae or checking urine are monitoring actions, not preventive instructions, and darkening the room is unrelated.