NCLEX-RN
Basic Adult Health Care NCLEX Heart Questions Questions
Extract:
Question 1 of 5
A client is admitted with a 6.5-cm thoracic aneurysm. The nurse records fi ndings from the initial assessment in the client’s chart, as shown below. At 10:30 a.m., the client complains of sharp midchest pain after having a bowel movement. What should the nurse do first?
Correct Answer: A
Rationale: The size of the thoracic aneurysm is rather large, so the nurse should anticipate rupture. A sudden incidence of pain may indicate leakage or rupture. The blood pressure and heart rate will provide useful information in assessing for hypovolemic shock. The nurse needs more data before initiating other interventions. After assessment of vital signs, neurologic status, and pain, the nurse can then contact the physician. Administering lactated Ringer’s solution would require a physician’s order
Question 2 of 5
A client with Ménière'sdisease continues to have disabling attacks of vertigo and elects to have a labyrinthectomy. A priority nursing diagnosis for the client before surgery is:
Correct Answer: B
Rationale: Risk for injury related to vertigo is the priority due to the high risk of falls and accidents during vertigo attacks, which is a significant concern pre-surgery.
Question 3 of 5
A client post-ureteroscopy reports burning on urination. The nurse should:
Correct Answer: A
Rationale: Burning is common post-ureteroscopy; fluids dilute urine, reducing irritation.
Question 4 of 5
During the assessment of a client's mouth, the nurse notes the absence of saliva. The client has pain in the area of the ear. The client has been nothing-by-mouth (NPO) for several days because of the insertion of a nasogastric tube. Based on these findings, the nurse suspects that the client may be developing which of the following mouth conditions?
Correct Answer: C
Rationale: Parotitis, inflammation of the parotid gland, is suggested by the absence of saliva and ear pain, especially in a client who is NPO and dehydrated, which can impair salivary gland function. Stomatitis, oral candidiasis, and gingivitis typically present with different symptoms, such as mucosal inflammation, white patches, or gum bleeding.
Question 5 of 5
The nurse should plan to begin rehabilitation efforts for the burn client:
Correct Answer: B
Rationale: Rehabilitation begins after stabilizing the client's circulatory status (emergent phase), as this ensures survival and allows focus on recovery. Immediate rehab is unsafe, and complete pain elimination is unrealistic.