NCLEX-RN
Adult Health Med Surg NCLEX Test Bank Questions
Extract:
Question 1 of 5
The nurse is assessing a client who has had a myocardial infarction (MI). The nurse notes the cardiac rhythm shown on the electrocardiogram strip below. The nurse identifies this rhythm as which of the following?
Correct Answer: N/A
Rationale: Without the ECG strip, the rhythm cannot be identified. This question is incomplete in the provided document.
Question 2 of 5
A client has an amylase level of 450 units/L and lipase level of 659 units/L. The client has mid-epigastric pain with nausea. What assessment helps the nurse to determine severity of the client's condition?
Correct Answer: A
Rationale: Ranson's criteria (
A) assess pancreatitis severity using clinical and lab parameters like age, glucose, and white blood cell count. Vital signs (
B) and urine output (
C) are general but less specific. Glasgow Coma Scale (
D) is for neurological assessment, not pancreatitis severity.
Question 3 of 5
Which complication should the nurse monitor for in a client with a new ileal conduit?
Correct Answer: A
Rationale: Stoma prolapse is a potential complication of an ileal conduit, requiring surgical correction if severe.
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 is to administer flumazenil (Mazicon) I.V. for reversal of sedation. Which of the following interventions should be included in the care plan? Select all that apply.
Correct Answer: B,C,D,E
Rationale: Flumazenil is given undiluted in incremental doses (
B), via a free-flowing IV line (
D), with monitoring for side effects like shivering and hypotension (
C) and level of consciousness (E). A 2-mg bolus (
A) is incorrect, as flumazenil is titrated in smaller doses.