NCLEX-RN
Adult Health Med Surg NCLEX Test Bank Questions
Extract:
Question 1 of 5
The primary reason for infusing blood at a rate of 60 mL/hour is to help prevent which of the following complications?
Correct Answer: B
Rationale: A slow infusion rate (60 mL/hour) prevents fluid volume overload, especially in clients at risk post-trauma. Emboli, hemolysis, and allergic reactions are less directly related to infusion rate.
Question 2 of 5
The nurse is caring for a client who has just had an ankle-brachial index (ABI) test. The left arm blood pressure was 160/80 mm Hg and a palpable systolic blood pressure of the left lower extremity was 130/60 mm Hg. These findings suggest that the client has:
Correct Answer: A
Rationale: ABI = ankle systolic BP ÷ arm systolic BP = 130 ÷ 160 = 0.81. An ABI of 0.8–0.9 indicates mild peripheral artery disease, suggesting some arterial narrowing. Normal ABI is 0.9–1.3, moderate is 0.5–0.8, and severe is <0.5.
Question 3 of 5
What is the earliest clinical manifestation in a client with acute disseminated intravascular coagulation (DIC)?
Correct Answer: B
Rationale: DIC causes widespread clotting and bleeding due to consumption of clotting factors and platelets. The earliest manifestation is often unexplained bleeding, such as petechiae or oozing from venipuncture sites. Shortness of breath, orthopnea, and hematuria are later or less specific signs.
Question 4 of 5
The nurse is reviewing laboratory reports for a client who is taking allopurinol (Zyloprim). Which of the following indicate that the drug has had a therapeutic effect?
Correct Answer: D
Rationale: Allopurinol reduces serum uric acid levels, indicating therapeutic effectiveness in preventing uric acid stone formation.
Question 5 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.