Basic Adult Health Care NCLEX Questions
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Question 1 of 5.
The client asks the nurse, 'Why can't the physician tell me exactly how much of my leg he's going to take off? Don't you think I should know that?' On which of the following should the nurse base the response?
A. The need to remove as much of the leg as possible.
B. The adequacy of the blood supply to the tissues.
C. The ease with which a prosthesis can be fitted.
D. The client's ability to walk with a prosthesis.
Explanation: The extent of amputation depends on tissue viability, determined by blood supply intraoperatively.
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.