NCLEX-RN
Adult Health Med Surg NCLEX Test Bank Questions
Extract:
Question 1 of 5
Which assessment finding is expected in the oliguric phase of acute renal failure?
Correct Answer: A
Rationale: Weight gain occurs due to fluid retention in the oliguric phase.
Question 2 of 5
Which one of the following assessments is most appropriate for determining the correct placement of an endotracheal tube in a mechanically ventilated client?
Correct Answer: D
Rationale: Auscultating bilateral breath sounds confirms correct endotracheal tube placement in both lungs. Skin color, respiratory rate, and cuff inflation are less specific.
Question 3 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.
Question 4 of 5
The surgeon orders cefazolin (Ancef) 1 g to be given I.V. at 7:30 a.m. when the client's surgery is scheduled at 8:00 a.m. What is the primary reason to start the antibiotic exactly at 7:30 a.m.?
Correct Answer: B
Rationale: Administering cefazolin 30 to 60 minutes before incision ensures optimal tissue levels to prevent surgical site infections. Timing is critical for prophylactic efficacy, not legal requirements or postoperative dosing schedules.
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.