NCLEX-RN
Adult Health Med Surg NCLEX Test Bank Questions
Extract:
Question 1 of 5
A nurse notes that a client has kyphosis and generalized muscle atrophy. Which of the following problems is a priority when the nurse develops a nursing plan of care?
Correct Answer: C
Rationale: Kyphosis and muscle atrophy impair chest expansion and cough effectiveness, increasing pneumonia complications. Ineffective coughing and deep breathing is the priority to clear secretions and prevent worsening infection. Infection is already present. Confusion and chewing difficulties are less immediate concerns.
Question 2 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 3 of 5
What is the earliest clinical manifestation in a client with acute disseminated intravascular coagulation (DIC)?
Correct Answer: B
Rationale: DIC causes widespread clotting and bleeding due to consumption of clotting factors and platelets. The earliest manifestation is often unexplained bleeding, such as petechiae or oozing from venipuncture sites. Shortness of breath, orthopnea, and hematuria are later or less specific signs.
Question 4 of 5
Which of the following should the nurse include in the teaching plan for a client with arterial insufficiency to the feet that is being managed conservatively?
Correct Answer: A
Rationale: Daily lubrication prevents skin breakdown in arterial insufficiency, improving circulation.
Question 5 of 5
Which of the following signs and symptoms would probably indicate that the client with Addison's disease is receiving too much glucocorticoid replacement?
Correct Answer: C
Rationale: Rapid weight gain indicates fluid retention, a sign of excessive glucocorticoid replacement.