NCLEX-RN
Adult Health Med Surg NCLEX Test Bank Questions
Extract:
Question 1 of 5
The nurse is planning care for an 80-year-old client with a pressure ulcer (see figure). The nurse should do which of the following? Select all that apply
Correct Answer: C,D,E
Rationale: The client has a Stage II pressure ulcer. The nurse should take measures to relieve the pressure, treat the local infection, and protect the wound. The nurse should keep the ulcer covered with a protective dressing.. The client should turn every 2 hours and use an alternating-pressure mattress to relieve pressure on the buttocks. The head of the bed should be elevated no more than 30 degrees. All wounds have bacteria and obtaining frequent cultures (unless ordered otherwise) are not necessary
Question 2 of 5
Which of the following rehabilitative measures should the nurse teach the client who has undergone chest surgery to prevent shoulder ankylosis?
Correct Answer: C
Rationale: Raising the arm overhead prevents shoulder ankylosis (stiffness) by maintaining range of motion post-chest surgery. Other movements are less specific to shoulder mobility.
Question 3 of 5
Which fluid is best for a client with renal calculi?
Correct Answer: C
Rationale: Water increases urine volume, reducing stone formation risk.
Question 4 of 5
A client with a spinal cord injury is at risk for autonomic dysreflexia. Which symptom should the nurse monitor for?
Correct Answer: C
Rationale: Excessive sweating above the injury level is a hallmark symptom of autonomic dysreflexia, a medical emergency.
Question 5 of 5
A client is about to undergo bone marrow aspiration of the sternum. Which of the following statements should the nurse include to provide information to the client about what the client will feel during the procedure?
Correct Answer: C
Rationale: During sternal bone marrow aspiration, the client may feel a brief pulling or pressure sensation as the marrow is aspirated. The antiseptic solution is not applied over such a large area, local anesthetic is injected (not sprayed), and a bandage is applied to the site, not around the chest.