NCLEX-RN
Adult Health Med Surg NCLEX Test Bank Questions
Extract:
Question 1 of 5
Which of the following activities should the nurse encourage the unlicensed assistive personnel to assist with in the care of postoperative clients? Select all that apply.
Correct Answer: A,B,D
Rationale: Unlicensed assistive personnel can empty/measure catheter bags (
A), reposition clients (
B), and report pain (
D). Teaching (
C) and assessing IV sites (E) require nursing judgment and are outside their scope.
Question 2 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.
Question 3 of 5
A client is being treated for deep vein thrombosis (DVT) in the left femoral artery. The physician has ordered 60 mg of enoxaparin (Lovenox) subcutaneously. Before administering the drug, the nurse checks the client's laboratory results, noted below. Based on these results, the nurse should:
Correct Answer: C
Rationale: Without specific lab results provided, the context implies abnormal values (e.g., low platelets or high INR) that increase bleeding risk with enoxaparin, a low-molecular-weight heparin. The nurse should inform the physician to evaluate the results before proceeding. Administering or withholding without consultation is unsafe, and assessing for bleeding is not the immediate action.
Question 4 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 5 of 5
Which fluid is best for a client with renal calculi?
Correct Answer: C
Rationale: Water increases urine volume, reducing stone formation risk.