NCLEX-RN
Adult Health Med Surg NCLEX Test Bank Questions
Extract:
Question 1 of 5
The nurse is assessing a client's left leg for neurovascular changes following a total left knee replacement. Which of the following are expected normal findings? Select all that apply.
Correct Answer: A,B,C
Rationale: Reduced edema, warm skin, and normal capillary refill are expected post-surgery. Pain is typically present, and pulses should be equal.
Question 2 of 5
Which one of the following assessments is most appropriate for determining the correct placement of an endotracheal tube in a mechanically ventilated client?
Correct Answer: D
Rationale: Auscultating bilateral breath sounds confirms correct endotracheal tube placement in both lungs. Skin color, respiratory rate, and cuff inflation are less specific.
Question 3 of 5
A client who has a history of an inguinal hernia is admitted to the hospital with sudden, severe abdominal pain, vomiting, and abdominal distention. The nurse should assess the client further for which of the following complications?
Correct Answer: C
Rationale: Sudden, severe abdominal pain, vomiting, and distention in a client with an inguinal hernia suggest a strangulated hernia, where the herniated tissue loses blood supply, requiring urgent assessment. Peritonitis, incarceration, or perforation are less likely without additional signs. CN: Physiological adaptation; CL: Analyze
Question 4 of 5
A client with type 1 diabetes mellitus is admitted to the emergency department. Which of the following respiratory patterns requires immediate action?
Correct Answer: A
Rationale: Deep, rapid respirations (Kussmaul respirations) indicate diabetic ketoacidosis, a life-threatening condition requiring immediate intervention.
Question 5 of 5
The physician orders intestinal decompression with a Cantor tube for a client with an intestinal obstruction. In order to determine effectiveness of intestinal decompression the nurse should evaluate the client to determine if:
Correct Answer: A
Rationale: The effectiveness of a Cantor tube is determined by the removal of fluid and gas from the intestine, relieving the obstruction. Bowel movements, urinary output, or sitting up without pain are not direct indicators of decompression success. CN: Physiological adaptation; CL: Evaluate