NCLEX-RN
Adult Health Med Surg NCLEX Test Bank Questions
Extract:
Question 1 of 5
The nurse's best explanation for why the severely neutropenic client is placed in reverse isolation is that reverse isolation helps prevent the spread of organisms:
Correct Answer: A
Rationale: Reverse isolation protects severely neutropenic clients by preventing the introduction of pathogens from external sources, such as staff, visitors, or equipment. It is not about preventing spread from the client or specific disposal/handling techniques.
Question 2 of 5
A client had a total abdominal hysterectomy and bilateral oophorectomy for ovarian carcinoma yesterday. She received 2 mg of morphine via PCA 10 minutes ago. The nurse was assisting her from the bed to a chair when the client felt dizzy and fell into the chair. The nurse should:
Correct Answer: C
Rationale: Dizziness after morphine suggests possible hypotension. Taking the blood pressure identifies the cause and guides further action, such as fluid administration or repositioning.
Question 3 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 4 of 5
A nurse notes that a client has kyphosis and generalized muscle atrophy. Which of the following problems is a priority when the nurse develops a nursing plan of care?
Correct Answer: C
Rationale: Kyphosis and muscle atrophy impair chest expansion and cough effectiveness, increasing pneumonia complications. Ineffective coughing and deep breathing is the priority to clear secretions and prevent worsening infection. Infection is already present. Confusion and chewing difficulties are less immediate concerns.
Question 5 of 5
A client has been admitted with acute renal failure. What should the nurse do? Select all that apply.
Correct Answer: B,C,D
Rationale: Taking vital signs, establishing IV access, and contacting the physician are immediate actions to assess and stabilize the client with acute renal failure.