The nurse cares for a client receiving mechanical ventilation who is p

Basic Adult Health Care NCLEX Questions

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Question 1 of 5.

The nurse cares for a client receiving mechanical ventilation who is prescribed one unit of packed red blood cells to be transfused. Which finding would alert the nurse of a transfusion-related reaction?

A. Low-pressure alarm

B. Increased blood glucose

C. Diminished lung sounds

D. Hemoglobinuria

Explanation: Hemoglobinuria (blood in the urine) is a hallmark of a hemolytic transfusion reaction, indicating red blood cell destruction. Low-pressure alarms relate to ventilator issues, increased glucose is unrelated, and diminished lung sounds may suggest other issues but not specifically transfusion reactions.

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.