NCLEX-RN
Adult Health Med Surg NCLEX Test Bank Questions
Extract:
Question 1 of 5
The primary goal for the client with Buerger's disease is to prevent:
Correct Answer: D
Rationale: The primary goal in Buerger's disease is to prevent gangrene, as the condition causes severe arterial and venous inflammation, leading to occlusion and tissue ischemia. Smoking cessation and vasodilation are key to avoiding tissue necrosis. Embolus, fat embolus, or thrombophlebitis are less specific concerns.
Question 2 of 5
The nurse is completing a health assessment of a 42-year-old female with suspected Graves' disease. The nurse should assess this client for:
Correct Answer: B
Rationale: Graves' disease, the most common type of thyrotoxicosis, is a state of hypermetabolism. The increased metabolic rate generates heat and produces tachycardia and fine muscle tremors. Anorexia is associated with hypothyroidism. Loss of weight, despite a good appetite and adequate caloric intake, is a common feature of hyperthyroidism. Cold skin is associated with hypothyroidism.
Question 3 of 5
A client with peripheral vascular disease has bypass surgery. The primary goal of the plan of care after surgery is to:
Correct Answer: A
Rationale: The primary goal post-bypass surgery for PVD is to maintain circulation, ensuring graft patency and adequate blood flow to the extremity to prevent ischemia or graft failure. Infection prevention, pain relief, and education are important but secondary to circulation.
Question 4 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
Question 5 of 5
After the administration of t-PA, the assessment priority is to:
Correct Answer: A
Rationale: Monitoring for chest pain post-t-PA assesses for reperfusion success or reocclusion, a priority to ensure effective thrombolysis and myocardial perfusion.