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Questions 158

NCLEX-RN

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Extract:


Question 1 of 5

The nurse is caring for a client with a history of congestive heart failure. The nurse should give priority to:

Correct Answer: A

Rationale: Congestive heart failure increases the risk of arrhythmias due to cardiac strain, making monitoring for arrhythmias a priority to prevent sudden cardiac events.

Question 2 of 5

The nurse is caring for a client with a diagnosis of oligohydramnios. Which finding is most likely to be present?

Correct Answer: A

Rationale: Oligohydramnios (low amniotic fluid) can restrict fetal movement due to limited space making decreased fetal movement a likely finding. Fetal heart rate may be normal or show distress uterine size is smaller and macrosomia is unrelated.

Question 3 of 5

The client is admitted with a diagnosis of gestational hypertension. Which vital sign change is most concerning?

Correct Answer: A

Rationale: A blood pressure of 160/110 indicates severe gestational hypertension increasing the risk of complications like stroke or eclampsia and requires immediate intervention. The other vital signs are normal.

Question 4 of 5

A client who had major abdominal surgery is having delayed healing of the wound. Which laboratory test result would most closely correlate with this problem?

Correct Answer: A

Rationale: Decreased albumin indicates protein deficiency, impairing tissue repair and delaying wound healing. Decreased creatinine (
B) reflects renal function, increased calcium (
C) affects bones, and increased sodium (
D) affects fluid balance, not healing directly.

Question 5 of 5

Which of the following signs might indicate a complication during the labor process with vertex presentation?

Correct Answer: D

Rationale: Fetal tachycardia may indicate fetal hypoxia; however, 170 bpm is only mild tachycardia. Nausea and vomiting occur frequently during transition and are not a complication. Contractions frequently last 60-90 seconds during the transitional phase of labor and are not considered a complication as long as the uterus relaxes completely between contractions. Passage of meconium in a vertex presentation is a sign of fetal distress; this may be normal in a breech presentation owing to pressure on the presenting part.

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