Adult Health Med Surg NCLEX Test Bank
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Question 1 of 5.
Extract: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
Explanation: 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 perfusionâ€â€all requiring immediate follow-up. Pulse oximetry (95%) and clear lung sounds are stable.
Question 2 of 5.
The nurse is assessing a client who has had a myocardial infarction (MI). The nurse notes the cardiac rhythm shown on the electrocardiogram strip below. The nurse identifies this rhythm as which of the following?
A. Atrial fibrillation.
B. Ventricular tachycardia.
C. Premature ventricular contractions (PVCs).
D. Third-degree heart block.
Explanation: Without the ECG strip, the rhythm cannot be identified. This question is incomplete in the provided document.
Question 3 of 5.
After the administration of t-PA, the assessment priority is to:
A. Monitor the client for chest pain.
B. Monitor for fever.
C. Monitor the 12-lead electrocardiogram (ECG) every 4 hours.
D. Monitor breath sounds.
Explanation: Monitoring for chest pain post-t-PA assesses for reperfusion success or reocclusion, a priority to ensure effective thrombolysis and myocardial perfusion.
Question 4 of 5.
A client has a throbbing headache when nitroglycerin is taken for angina. The nurse should instruct the client that:
A. Acetaminophen (Tylenol) or Ibuprofen (Advil) can be taken for this common side effect.
B. Nitroglycerin should be avoided if the client is experiencing this serious side effect.
C. Taking the nitroglycerin with a few glasses of water will reduce the problem.
D. The client should lie in a supine position to alleviate the headache.
Explanation: Headache is a common side effect of nitroglycerin due to vasodilation. Acetaminophen or ibuprofen can safely relieve it without discontinuing the medication.
Question 5 of 5.
A client has returned from the cardiac catheterization laboratory after a balloon valvuloplasty for mitral stenosis. Which of the following requires immediate nursing action?
A. A low, grade 1 intensity mitral regurgitation murmur.
B. SpO2 is 94% on 2 liters of oxygen via nasal cannula.
C. The client has become more somnolent.
D. Urine output has decreased from 60 mL/hour to 40 mL over the last hour.
Explanation: Increased somnolence may indicate neurological complications (e.g., stroke) post-valvuloplasty, requiring immediate action. Other findings are less urgent.
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