Basic Adult Health Care NCLEX Questions
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Question 1 of 5.
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.
Explanation: Saliva collecting beneath skin flaps post-laryngectomy indicates a fistula, where saliva leaks from the pharynx or esophagus into surrounding tissues, requiring immediate attention.
Question 2 of 5.
If the client who was admitted for myocardial infarction (MI) develops cardiogenic shock, which characteristic sign should the nurse expect to observe?
A. Oliguria.
B. Bradycardia.
C. Elevated blood pressure.
D. Fever.
Explanation: Cardiogenic shock causes decreased cardiac output, leading to reduced renal perfusion and oliguria (low urine output). Bradycardia, elevated BP, and fever are not typical signs.
Question 3 of 5.
Contraindications to the administration of tissue plasminogen activator (t-PA) include which of the following?
A. Age greater than 60 years.
B. History of cerebral hemorrhage.
C. History of heart failure.
D. Cigarette smoking.
Explanation: A history of cerebral hemorrhage is an absolute contraindication to t-PA due to the risk of bleeding. Age, heart failure, and smoking are not contraindications.
Question 4 of 5.
A client with angina has been taking nifedipine. The nurse should teach the client to:
A. Monitor blood pressure monthly.
B. Perform daily weights.
C. Inspect gums daily.
D. Limit intake of green leafy vegetables.
Explanation: Nifedipine, a calcium channel blocker, can cause gingival hyperplasia. Daily gum inspection helps detect this side effect early.
Question 5 of 5.
A client is scheduled for a cardiac catheterization. The nurse should do which of the following preprocedure tasks? Select all that apply.
A. Administer all ordered oral medications.
B. Check for iodine sensitivity.
C. Verify that written consent has been obtained.
D. Withhold food and oral fluids before the procedure.
E. Insert a urinary drainage catheter.
Explanation: Checking iodine sensitivity (B), verifying consent (C), and withholding food/fluids (D) are standard pre-catheterization tasks to ensure safety and preparedness.
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