NCLEX-RN
Adult Health Med Surg NCLEX Test Bank Questions
Extract:
Question 1 of 5
In the early postoperative period after a bilateral adrenalectomy, the client has an increased temperature. The nurse should assess the client further for signs of:
Correct Answer: C
Rationale: An increased temperature post-adrenalectomy suggests wound infection, a common postoperative complication requiring prompt assessment.
Question 2 of 5
Which of the following activities should the nurse encourage the unlicensed assistive personnel to assist with in the care of postoperative clients? Select all that apply.
Correct Answer: A,B,D
Rationale: Unlicensed assistive personnel can empty/measure catheter bags (
A), reposition clients (
B), and report pain (
D). Teaching (
C) and assessing IV sites (E) require nursing judgment and are outside their scope.
Question 3 of 5
A client is being treated for deep vein thrombosis (DVT) in the left femoral artery. The physician has ordered 60 mg of enoxaparin (Lovenox) subcutaneously. Before administering the drug, the nurse checks the client's laboratory results, noted below. Based on these results, the nurse should:
Correct Answer: C
Rationale: Without specific lab results provided, the context implies abnormal values (e.g., low platelets or high INR) that increase bleeding risk with enoxaparin, a low-molecular-weight heparin. The nurse should inform the physician to evaluate the results before proceeding. Administering or withholding without consultation is unsafe, and assessing for bleeding is not the immediate action.
Question 4 of 5
A 20-year-old who hit his head while playing football has a tonic-clonic seizure. Upon awakening from the seizure, the client asks the nurse, "What caused me to have a seizure? I've never had one before." Which cause should the nurse include in the response as a primary cause of tonic-clonic seizures in adults older than age 20?
Correct Answer: A
Rationale: Head trauma is a primary cause of seizures in adults over 20, especially in the context of a recent injury. Electrolyte imbalances, congenital defects, or epilepsy are less likely without additional history.
Question 5 of 5
The nurse in the intensive care unit is giving a report to the nurse in a cardiac step-down unit about a client who had coronary artery bypass surgery. Which of the following is the most effective way to assure essential information about the client is reported?
Correct Answer: C
Rationale: A printed checklist individualized for the client ensures all essential information is systematically communicated, reducing errors during handoff.