NCLEX-RN
Adult Health II Respiratory NCLEX Questions Questions
Extract:
Question 1 of 5
When the nurse administers I.V. midazolam hydrochloride (Versed), the client demonstrates signs of an overdose. The nurse should next collaborate with the surgical team to:
Correct Answer: D
Rationale: Flumazenil is the specific reversal agent for benzodiazepine overdose, such as with midazolam. Titrating flumazenil reverses sedation and respiratory depression effectively.
Question 2 of 5
Which assessment is most important for a client receiving mannitol?
Correct Answer: B
Rationale: Urine output is critical to monitor for mannitol's diuretic effect in reducing intracranial pressure.
Question 3 of 5
The nurse assesses the client's stoma during the initial postoperative period. Which of the following observations should be reported immediately to the physician?
Correct Answer: B
Rationale: A dark red to purple stoma indicates inadequate blood supply, which is a medical emergency requiring immediate reporting to the physician. Slight edema is expected post-surgery, a small amount of blood oozing is normal, and lack of stool expulsion in the initial period may not be immediately concerning unless other symptoms are present. CN: Physiological adaptation; CL: Analyze
Question 4 of 5
A client who had an appendectomy for a perforated appendix returns from surgery with a drain inserted in the incisional site. The purpose of the drain is to:
Correct Answer: B
Rationale: The drain in the incisional site of a perforated appendix promotes drainage of wound exudate to prevent infection and abscess formation. It is not for irrigation, scar prevention, or direct pain relief. CN: Physiological adaptation; CL: Apply
Question 5 of 5
The nurse has established a goal with a client to improve mobility following hip replacement. Which of the following is a realistic outcome at the time of discharge from the surgical unit?
Correct Answer: C
Rationale: Increased independence in transfers is a realistic and measurable goal for discharge.