NCLEX-RN
Adult Health Med Surg NCLEX Test Bank Questions
Extract:
Question 1 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 2 of 5
A nurse is teaching a client about taking antihistamines. Which of the following instructions should the nurse include in the teaching plan? Select all that apply.
Correct Answer: A,D,E
Rationale: Antihistamines have an anticholinergic action and a drying effect and reduce nasal, salivary, and lacrimal gland hypersecretion (runny nose, tearing, and itching eyes). An adverse effect is drowsiness, so operating machinery and driving are not recommended. There is also an additive depressant effect when alcohol is combined with antihistamines, so alcohol should be avoided during antihistamine use. The client should ensure adequate fluid intake of at least 8 glasses per day due to the drying effect of the drug.
Question 3 of 5
A 20-year-old who hit his head while playing football has a tonic-clonic seizure. Upon awakening from the seizure, the client asks the nurse, "What caused me to have a seizure? I've never had one before." Which cause should the nurse include in the response as a primary cause of tonic-clonic seizures in adults older than age 20?
Correct Answer: A
Rationale: Head trauma is a primary cause of seizures in adults over 20, especially in the context of a recent injury. Electrolyte imbalances, congenital defects, or epilepsy are less likely without additional history.
Question 4 of 5
A client who had a gastrectomy has been in the postanesthesia recovery room for 30 minutes when his vital signs suddenly change. In addition to notifying the physician, what other action should the nurse take immediately?
Correct Answer: A
Rationale: Sudden vital sign changes post-gastrectomy suggest hypoxia or shock. Administering oxygen addresses potential respiratory compromise, a common postoperative issue, while awaiting physician guidance.
Question 5 of 5
The physician prescribes metoclopramide hydrochloride (Reglan) for the client with hiatal hernia. The nurse plans to instruct the client that this drug is used in hiatal hernia therapy to accomplish which of the following objectives?
Correct Answer: C
Rationale: Metoclopramide promotes gastric emptying, reducing the volume of gastric contents that can reflux in hiatal hernia.