Basic Adult Health Care NCLEX Questions

Basic Adult Health Care NCLEX Questions Related

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The nurse in the emergency department (ED) is caring for a 62-year-old male client.
Item 3 of 6
Triage Note
1700:
• The client was brought to the ED after collapsing on a tennis court.
• Vital signs: BP 94/57, T 105° F (40.5° C), P 115, RR 26, Pulse oximetry 95% on room air. • The client is lethargic and confused. Skin is pale, and there is some perspiration on the forehead. Thready peripheral pulses, clear lung fields bilaterally, tachypnea, shallow respirations.

The client is at highest risk for developing ……………..

  • A. stroke.
  • B. multiple organ dysfunction.
  • C. a myocardial infarction.
  • D. respiratory acidosis.
Correct Answer: B

Rationale: The client's severe hyperthermia, hypotension, tachycardia, and confusion suggest heat stroke, which can lead to multiple organ dysfunction due to systemic inflammation and hypoperfusion. Stroke (A), myocardial infarction (C), and respiratory acidosis (D) are less directly associated with heat stroke complications.

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The nurse is assessing the urine of a client who has had an ileal conduit and notes that the urine is yellow with a moderate amount of mucus. Based on the data, the nurse should?

  • A. Change the appliance bag.
  • B. Notify the physician.
  • C. Obtain a urine specimen for culture.
  • D. Encourage a high fluid intake.
Correct Answer: D

Rationale: Yellow urine with moderate mucus is normal for an ileal conduit due to intestinal segment use. Encouraging high fluid intake prevents complications like calculi or infection.

A client with multiple myeloma is admitted with a serum calcium level of 13.2 mg/dL. Which of the following nursing interventions is the priority?

  • A. Administer oral calcium supplements.
  • B. Encourage ambulation.
  • C. Administer I.V. normal saline.
  • D. Restrict fluid intake.
Correct Answer: C

Rationale: Hypercalcemia (serum calcium >10.5 mg/dL) in multiple myeloma requires urgent I.V. normal saline to promote calcium excretion and prevent renal damage, making it the priority intervention.

Which fluid is best for a client with renal calculi?

  • A. Cranberry juice.
  • B. Cola.
  • C. Water.
  • D. Milk.
Correct Answer: C

Rationale: Water increases urine volume, reducing stone formation risk.

A 56-year-old female is currently receiving radiation therapy to the chest wall for recurrent breast cancer. She has pain while swallowing and burning and tightness in her chest. The nurse should further assess the client for indications of:

  • A. Hiatal hernia.
  • B. Stomatitis.
  • C. Radiation enteritis.
  • D. Esophagitis.
Correct Answer: D

Rationale: Pain while swallowing and chest burning/tightness suggest esophagitis, a common side effect of chest wall radiation due to irritation of the esophageal mucosa.

Following a laryngectomy, the nurse notices that the client has saliva collecting beneath the skin flaps. This finding is indicative of which of the following?

  • A. Skin necrosis.
  • B. Carotid artery rupture.
  • C. Stomal Stenosis.
  • D. Development of a fistula.
Correct Answer: D

Rationale: Saliva collecting beneath skin flaps post-laryngectomy indicates a fistula, where saliva leaks from the pharynx or esophagus into surrounding tissues, requiring immediate attention.

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