NCLEX-RN
Basic Adult Health Care NCLEX Heart Questions Questions
Extract:
Question 1 of 5
A client says, 'I hate the idea of being an invalid after they cut off my leg.' Which of the following would be the nurse's most therapeutic response?
Correct Answer: B
Rationale: Encouraging the client to express feelings fosters coping and addresses emotional concerns.
Question 2 of 5
The nurse is caring for a client with acute arterial occlusion of the left lower extremity. To prevent further tissue damage, it is important for the nurse to observe for which of the following:
Correct Answer: B
Rationale: Acute arterial occlusion causes ischemia, leading to loss of sensory (numbness) and motor function (weakness) in the affected limb. Monitoring for these changes is critical to detect progression and prevent tissue damage. Blood pressure/heart rate, metabolic acidosis, and swelling are less specific or late findings.
Question 3 of 5
Which of the following activities should the nurse teach the client to implement after the removal of nasal packing on the second postoperative day?
Correct Answer: B
Rationale: Applying water-soluble jelly lubricates the nares, preventing crusting and discomfort post-packing removal. Cleaning is safe once packing is removed. A drip pad is unnecessary unless bleeding persists. Irrigation with a bulb syringe is not standard care.
Question 4 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 5 of 5
During the initial stage of adaptation to the diagnosis of cancer and its treatment, the nurse can facilitate the client's adaptation by:
Correct Answer: D
Rationale: Arranging transportation and child care addresses practical barriers, facilitating the client's ability to focus on treatment and adapt to the diagnosis.