NCLEX-RN
Basic Adult Health Care NCLEX Heart Questions Questions
Extract:
Question 1 of 5
A client is being monitored for transient ischemic attacks. She is oriented, can open her eyes spontaneously, and follows commands. What is her Glasgow Coma Scale score?
Correct Answer: 15
Rationale: The Glasgow Coma Scale assesses eye opening (4 for spontaneous), verbal response (5 for oriented), and motor response (6 for following commands). The client's score is 4 + 5 + 6 = 15.
Question 2 of 5
Which of the following goals is a priority for a client who has undergone surgery for retinal detachment?
Correct Answer: B
Rationale: Preventing an increase in intraocular pressure is the priority to protect the surgical repair and prevent complications like re-detachment or hemorrhage.
Question 3 of 5
A nurse is admitting a client who has been admitted with a diagnosis of upper GI bleeding to the hospital. The nurse should assess the client for which of the following? Select all that apply.
Correct Answer: A,B,C,E,F
Rationale: Upper GI bleeding can lead to hypovolemia, causing dry, flushed skin, decreased urine output, tachycardia, rapid respirations, and thirst. Widening pulse pressure is not typically associated with hypovolemia.
Question 4 of 5
A client returned from surgery with a debrided open tibial fracture and has a three-way drainage system. The nurse should first:
Correct Answer: D
Rationale: Checking blood pressure for hypotension is the priority, as bleeding from an open fracture can be life-threatening.
Question 5 of 5
In addition to nausea and severe flank pain, a female client with renal calculi has pain in the groin and bladder. The nurse should assess the client further for six years of:
Correct Answer: B
Rationale: Groin and bladder pain in renal calculi often indicate referred pain from the stone's movement or irritation along the urinary tract.