Adult Health Med Surg NCLEX Test Bank

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The nurse in the emergency department (ED) is caring for a 62-year-old male client.
Item 1 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.

Which of the following assessment findings from the triage note require immediate follow-up? Select all that apply.

  • A. blood pressure
  • B. temperature
  • C. pulse and respirations
  • D. pulse oximetry
  • E. lung sounds
  • F. neurological assessment findings
  • G. thready peripheral pulses
Correct Answer: A,B,C,F,G

Rationale: Blood pressure (94/57) indicates hypotension, temperature (105°F) suggests hyperthermia, pulse (115) and respirations (26) indicate tachycardia and tachypnea, neurological findings (lethargy, confusion) suggest altered mental status, and thready pulses indicate poor perfusion—all requiring immediate follow-up. Pulse oximetry (95%) and clear lung sounds are stable.

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When discussing recent onset of feelings of sadness and depression in a client with hypothyroidism, the nurse should inform the client that these feelings are:

  • A. The effects of thyroid hormone replacement therapy and will diminish over time.
  • B. Related to thyroid hormone replacement therapy and will not diminish over time.
  • C. A normal part of having a chronic illness.
  • D. Most likely related to low thyroid hormone levels and will improve with treatment.
Correct Answer: D

Rationale: Low thyroid hormone levels in hypothyroidism can cause depression and sadness, which typically improve with thyroid hormone replacement therapy.

Which of the following health promotion activities would be appropriate for the nurse to suggest that the client with cirrhosis add to the daily routine at home?

  • A. Supplement the diet with daily multivitamins.
  • B. Limit daily alcohol intake.
  • C. Take a sleeping pill at bedtime.
  • D. Limit contact with other people whenever possible.
Correct Answer: A

Rationale: Multivitamins (A) support nutrition in cirrhosis. Alcohol (B) must be avoided entirely. Sleeping pills (C) risk encephalopathy. Social isolation (D) is unnecessary.

Which of the following factors would have the least influence on the survival and effectiveness of a burn victim's porcine grafts?

  • A. Absence of infection in the wounds.
  • B. Adequate vascularization in the grafted area.
  • C. Immobilization of the area being grafted.
  • D. Use of analgesics as necessary for pain relief.
Correct Answer: D

Rationale: Analgesics manage pain but do not directly affect graft survival. Infection control, vascularization, and immobilization are critical for graft adherence and effectiveness.

The client has midcalf pain when walking a block or more. The client states that the discomfort is relieved with rest. The pain is expected when arterial occlusion reaches which of the following percentages?

  • A. 20%
  • B. 40%
  • C. 50%
  • D. 100%
Correct Answer: C

Rationale: Claudication typically occurs when arterial occlusion reaches approximately 50%, significantly reducing blood flow to muscles during activity. This causes ischemia and pain, which is relieved by rest when oxygen demand decreases. Complete (100%) occlusion would cause rest pain or tissue necrosis, not just claudication.

The client who had an open femoral fracture was discharged to her home where she developed fever, night sweats, chills, restlessness, and restrictive movement of the fractured leg. Which of the following reflects the best interpretation of these findings?

  • A. Pulmonary emboli.
  • B. Osteomyelitis.
  • C. Fat emboli.
  • D. Urinary tract infection.
Correct Answer: B

Rationale: These symptoms suggest osteomyelitis, a bone infection common after open fractures.

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