NCLEX-RN
Basic Adult Health Care NCLEX Heart Questions Questions
Extract:
Question 1 of 5
A client with aortic stenosis complains of increasing dyspnea and dizziness. Identify the area where the nurse would place the stethoscope to assess a murmur from aortic stenosis.
Correct Answer: A
Rationale: The stethoscope is placed at the second intercostal space right of sternum (1) to assess the aortic area. (2) is the pulmonic valve area, (3) is Erb’s point, (4) is the Tricuspid valve area, and (5) is the Mitral valve area.
Question 2 of 5
A terminally ill 82-year-old client in hospice care is experiencing nausea and vomiting because of a partial bowel obstruction. To respect the client's wishes for conservative management of the nausea and vomiting, the nurse should recommend the use of:
Correct Answer: B
Rationale: I.V. antiemetics are a conservative, effective way to manage nausea and vomiting in hospice care, aligning with the client's preference for non-invasive treatment.
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 52-year-old client with lung cancer tells the nurse that he has a low-grade fever (100.6°F [38.1°C]), nonproductive cough, and increasing fatigue. He completed the radiation therapy to the mass in his right lung and mediastinum 10 weeks ago and has a follow-up appointment to see the physician in 2 weeks. What is the most appropriate response by the nurse?
Correct Answer: C
Rationale: Fever, cough, and fatigue post-radiation may indicate infection or pneumonitis, requiring prompt evaluation, especially in a lung cancer patient, so an office visit today is appropriate.
Question 5 of 5
The nurse is assessing a 48-year-old client with a history of smoking during a routine clinic visit. The client, who exercises regularly, reports having pain in the calf during exercise that disappears at rest. Which of the following findings requires further evaluation?
Correct Answer: D
Rationale: An ankle-brachial index (ABI) of 0.65 is significantly below the normal range (0.9–1.3), indicating potential peripheral vascular disease (PV
D) due to arterial insufficiency. This finding warrants further evaluation, especially given the client's symptoms of claudication (pain during exercise relieved by rest) and smoking history, which are risk factors for PVD. The other options€”heart rate, SpO2, and blood pressure€”are either normal or irrelevant in this context.