NCLEX-RN
Basic Adult Health Care NCLEX Heart Questions Questions
Extract:
Question 1 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 2 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 3 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.
Question 4 of 5
A client with allergic rhinitis is instructed on the correct technique for using an intranasal inhaler. Which the patient is the client should demonstrate to the nurse that the client understands the instructions?
Correct Answer: C
Rationale: Holding one nostril closed while spraying into the other ensures proper delivery of the medication to the nasal mucosa. Limiting use to specific times is not typically required unless specified by the prescriber. Shaking the canister is often necessary for some inhalers to mix the medication. Pointing the inhaler toward the inner nostril wall is incorrect; it should be directed upward and slightly outward.
Question 5 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.