NCLEX-RN
Basic Adult Health Care NCLEX Questions Questions
Extract:
Question 1 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 2 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 3 of 5
A client is recovering from an abdominal-perineal resection. Which of the following measures would most effectively promote wound healing after the perineal drains have been removed?
Correct Answer: A
Rationale: Sitz baths promote wound healing by improving circulation, reducing inflammation, and keeping the perineal area clean after an abdominal-perineal resection. Moist heat packs, irrigations, or packing are less effective or not standard for this purpose. CN: Physiological adaptation; CL: Synthesize
Question 4 of 5
Which of the following complications is associated with mechanical ventilation?
Correct Answer: D
Rationale: Mechanical ventilation increases the risk of pulmonary emboli due to immobility and hypercoagulability. Gastrointestinal hemorrhage, immunosuppression, and increased cardiac output are less directly related.
Question 5 of 5
The client's identification armband was removed to start an I.V. line as a part of the preoperative preparation. The transport team has arrived to transport the client to the operating room. The nurse notices that the client's identification band is not on his wrist. What is the nurse's best response?
Correct Answer: B
Rationale: Placing a new identification armband ensures accurate client identification during transport and surgery, maintaining safety and compliance with protocol.