NCLEX-RN
Adult Health Med Surg NCLEX Test Bank Questions
Extract:
Question 1 of 5
Which of the following statements would indicate to the nurse that the client who has undergone repair of her nasal septum has understood the discharge instructions?
Correct Answer: B
Rationale: Taking stool softeners and modifying the diet to prevent constipation avoids straining (Valsalva's maneuver), which could cause bleeding or complications post-nasal surgery.
Question 2 of 5
Which of the following lab values should the nurse report to the health care provider when the client has anemia?
Correct Answer: B
Rationale: An absent intrinsic factor is a critical finding in clients with anemia, as it indicates pernicious anemia, a condition where the body cannot absorb vitamin B12 due to a lack of intrinsic factor. This requires immediate medical attention and lifelong B12 supplementation. An elevated Schilling test is not a standard result (the test measures B12 absorption), a sedimentation rate of 16 mm/hour is normal, and normal RBCs do not explain anemia.
Question 3 of 5
The nurse is assessing a client for movement after halo traction placement for a C8 fracture. The nurse should document which of the following?
Correct Answer: A
Rationale: A C8 fracture affects the lower cervical nerves, but shoulder shrug (trapezius, innervated by cranial nerve XI and C3-C4) should remain intact. Arm movements and hand grasp involve C5-C8 and may be impaired, making shoulder shrug the most reliable intact movement to document.
Question 4 of 5
The nurse is instructing a young adult with Addison's disease how to adjust the dose of glucocorticoids. The nurse should explain that the client may need an increased dosage of glucocorticoids in which of the following situations?
Correct Answer: D
Rationale: Stressful situations like surgery or dental procedures (e.g., root canal) increase glucocorticoid needs in Addison's disease to prevent adrenal crisis.
Question 5 of 5
There is a shooting in a shopping mall. Three victims with gunshot wounds are brought to the emergency department. What should the nurse do to preserve forensic evidence? Select all that apply.
Correct Answer: B
Rationale:
To preserve forensic evidence, clothing should be placed in separate paper bags to prevent cross-contamination. Cutting around blood stains or placing bullets in sterile containers may damage evidence, and documentation of statements is necessary for legal purposes.