NCLEX-RN
Adult Health Med Surg NCLEX Test Bank Questions
Extract:
Question 1 of 5
When comparing the hematocrit levels of a postoperative client, the nurse notes that the hematocrit decreased from 36% to 34% on the third day even though the RBC count and hemoglobin value remained within 10 mg/dL and 11.9 g/dL, respectively. The nurse should:
Correct Answer: C
Rationale: A slight decrease in hematocrit (36% to 34%) on postoperative day 3, with stable RBC count and hemoglobin, is likely due to hemodilution from fluid administration rather than active bleeding. The nurse should continue to monitor vital signs and hematologic parameters. Checking for bleeding is unnecessary without signs of hemorrhage, calling the physician is premature, and oxygen is not indicated.
Question 2 of 5
The nurse is to administer flumazenil (Mazicon) I.V. for reversal of sedation. Which of the following interventions should be included in the care plan? Select all that apply.
Correct Answer: B,C,D,E
Rationale: Flumazenil is given undiluted in incremental doses (
B), via a free-flowing IV line (
D), with monitoring for side effects like shivering and hypotension (
C) and level of consciousness (E). A 2-mg bolus (
A) is incorrect, as flumazenil is titrated in smaller doses.
Question 3 of 5
The nurse is preparing the client for cardioversion. The nurse should do which of the following? Select all that apply.
Correct Answer: A,C,D,E
Rationale: Using a conducting agent (
A), calling 'clear' (
C), recording energy/rhythm (
D), and applying pressure (E) ensure safe and effective cardioversion. Paddles over clothing is incorrect.
Question 4 of 5
In the early postoperative period after a bilateral adrenalectomy, the client has an increased temperature. The nurse should assess the client further for signs of:
Correct Answer: C
Rationale: An increased temperature post-adrenalectomy suggests wound infection, a common postoperative complication requiring prompt assessment.
Question 5 of 5
A client has renal colic due to renal lithiasis. What is the nurse's first priority in managing care for this client?
Correct Answer: D
Rationale: Severe pain from renal colic is the priority, requiring opioid analgesics for immediate relief to improve client comfort and cooperation.