NCLEX-RN
Adult Health II Respiratory NCLEX Questions Questions
Extract:
Question 1 of 5
The nurse assesses the client's stoma during the initial postoperative period. Which of the following observations should be reported immediately to the physician?
Correct Answer: B
Rationale: A dark red to purple stoma indicates inadequate blood supply, which is a medical emergency requiring immediate reporting to the physician. Slight edema is expected post-surgery, a small amount of blood oozing is normal, and lack of stool expulsion in the initial period may not be immediately concerning unless other symptoms are present. CN: Physiological adaptation; CL: Analyze
Question 2 of 5
A client is admitted with a bowel obstruction. The client has nausea, vomiting, and crampy abdominal pain. The physician has written orders for the client to be up ad lib, to have narcotics for pain, to have a nasogastric tube inserted if needed, and for I.V. Ringer's Lactate and hyperalimentation fluids. The nurse should do the following in order of priority from first to last:
Order the Items
Source Container
Correct Answer: B,C,A,D
Rationale: The priority is to administer Ringer's Lactate (
B) to correct dehydration, followed by inserting a nasogastric tube (
C) if needed to decompress the bowel. Ambulation (
A) can promote peristalsis but is less urgent, and hyperalimentation fluids (
D) are started later for long-term nutrition. CN: Physiological adaptation; CL: Synthesize
Question 3 of 5
The nurse notes that the sterile, occlusive dressing on the central catheter insertion site of a client receiving total parenteral nutrition (TPN) is moist. The client is breathing easily with no abnormal breath sounds. The nurse should do the following in order of what priority from first to last?
Order the Items
Source Container
Correct Answer: C,B,A,D
Rationale: The priority is to notify the physician (
C) due to potential infection indicated by a moist dressing, followed by culturing drainage (
B) to identify the organism, changing the dressing (
A) to maintain sterility, and positioning a towel (
D), which is unrelated to the immediate issue. CN: Pharmacological and parenteral therapies; CL: Synthesize
Question 4 of 5
A client who had an appendectomy for a perforated appendix returns from surgery with a drain inserted in the incisional site. The purpose of the drain is to:
Correct Answer: B
Rationale: The drain in the incisional site of a perforated appendix promotes drainage of wound exudate to prevent infection and abscess formation. It is not for irrigation, scar prevention, or direct pain relief. CN: Physiological adaptation; CL: Apply
Question 5 of 5
The nurse observes that a client's ileostomy output is green and watery. Which action should the nurse take first?
Correct Answer: B
Rationale: Green, watery output is normal for an ileostomy, especially early post-surgery, and should be documented. Notifying the physician, increasing fiber, or giving antidiarrheals are unnecessary unless other symptoms arise. CN: Physiological adaptation; CL: Synthesize