NCLEX-RN
Adult Health II Respiratory NCLEX Questions Questions
Extract:
Question 1 of 5
The nurse instructs the client on health maintenance activities to help control symptoms from her hiatal hernia. Which of the following statements would indicate that the client has understood the instructions?
Correct Answer: A
Rationale: Avoiding lying down after meals prevents reflux, indicating the client understands hiatal hernia management. The other statements are incorrect or irrelevant.
Question 2 of 5
A postoperative client is prescribed enoxaparin (Lovenox) 40 mg subcutaneous daily. Which laboratory value should the nurse monitor?
Correct Answer: A
Rationale: Enoxaparin can cause thrombocytopenia. Monitoring platelet count ensures early detection of this potential adverse effect.
Question 3 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 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
A nurse is obtaining consent for a bone marrow aspiration. What should the nurse do? Select all that apply.
Correct Answer: A,B,D,E
Rationale: The nurse's role in obtaining consent includes witnessing the signature, ensuring the client understands the procedure and postprocedure care, and verifying voluntary consent. Explaining risks is typically the physician's responsibility.