NCLEX-RN
Adult Health Med Surg NCLEX Test Bank Questions
Extract:
Question 1 of 5
The nurse prepares a teaching plan for a client about crutch walking using a two-point gait pattern. Which of the following should the nurse include?
Correct Answer: B
Rationale: The two-point gait involves simultaneous advancement of one crutch and the opposite foot, mimicking natural walking.
Question 2 of 5
A client has an epidural catheter inserted for postoperative pain management. The client rates his pain at 4 on a 0-to-5 pain scale. What should the nurse do first?
Correct Answer: C
Rationale: Assessing vital signs first ensures the client is stable, as a pain level of 4 may indicate complications (e.g., respiratory depression). Checking the pump, adjusting the catheter, or notifying the physician follow if needed.
Question 3 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 4 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 5 of 5
A client receiving TPN reports sudden chest pain and dyspnea. Which action should the nurse take first?
Correct Answer: C
Rationale: Sudden chest pain and dyspnea in a client receiving TPN may indicate a serious complication like an air embolism or infection, requiring immediate physician notification. Stopping the infusion or checking glucose is premature, and oxygen requires an order. CN: Physiological adaptation; CL: Synthesize