NCLEX-RN
NCLEX RN Practice Questions Quizlet Questions
Extract:
Question 1 of 5
A patient admitted to the hospital with myocardial infarction develops severe pulmonary edema. Which of the following symptoms should the nurse expect the patient to exhibit?
Correct Answer: D
Rationale: In a patient with pulmonary edema following a myocardial infarction, the nurse should expect symptoms such as air hunger, anxiety, and agitation. Air hunger refers to the feeling of needing to breathe more deeply or more often. Other symptoms of pulmonary edema can include coughing up blood or bloody froth, orthopnea (difficulty breathing when lying down), and paroxysmal nocturnal dyspnea (sudden awakening with shortness of breath). Slow, deep respirations (
Choice
A) are not typical in pulmonary edema; these patients often exhibit rapid, shallow breathing due to the difficulty in oxygen exchange. Stridor (
Choice
B) is a high-pitched breathing sound often associated with upper airway obstruction, not typically seen in pulmonary edema. Bradycardia (
Choice
C), a slow heart rate, is not a characteristic symptom of pulmonary edema, which is more likely to be associated with tachycardia due to the body's compensatory response to hypoxia and increased workload on the heart.
Question 2 of 5
A patient admitted to the hospital with myocardial infarction develops severe pulmonary edema. Which of the following symptoms should the nurse expect the patient to exhibit?
Correct Answer: D
Rationale: In a patient with pulmonary edema following a myocardial infarction, the nurse should expect symptoms such as air hunger, anxiety, and agitation. Air hunger refers to the feeling of needing to breathe more deeply or more often. Other symptoms of pulmonary edema can include coughing up blood or bloody froth, orthopnea (difficulty breathing when lying down), and paroxysmal nocturnal dyspnea (sudden awakening with shortness of breath). Slow, deep respirations (
Choice
A) are not typical in pulmonary edema; these patients often exhibit rapid, shallow breathing due to the difficulty in oxygen exchange. Stridor (
Choice
B) is a high-pitched breathing sound often associated with upper airway obstruction, not typically seen in pulmonary edema. Bradycardia (
Choice
C), a slow heart rate, is not a characteristic symptom of pulmonary edema, which is more likely to be associated with tachycardia due to the body's compensatory response to hypoxia and increased workload on the heart.
Question 3 of 5
The nurse is caring for a 27-year-old female client with a venous stasis ulcer. Which nursing intervention would be most effective in promoting healing?
Correct Answer: B
Rationale: Venous stasis occurs when venous blood collects and stagnates in the lower leg due to incompetent venous valves. This leads to inadequate oxygen and nutrient supply to the cells in the lower extremities, resulting in cell death or necrosis. Venous stasis ulcers, characterized by shallow brown wounds with irregular margins, typically develop on the lower leg or ankle. The primary goal in managing clients with venous stasis ulcers is to promote healing. Proper nutrition plays a crucial role in wound healing. Nutritional deficiencies are common causes of venous ulcers, and a diet rich in protein, iron, zinc, and vitamins C and A is recommended to enhance wound healing. Applying dressings with sterile technique, initiating limb compression therapy, and beginning proteolytic debridement are important interventions in wound care but may not directly address the underlying issue of poor nutrition that is essential for healing venous stasis ulcers.
Question 4 of 5
A patient underwent fiberoptic colonoscopy 18 hours ago and presents to the emergency department with increasing abdominal pain, fever, and chills. Which of the following conditions poses the most immediate concern?
Correct Answer: A
Rationale: The correct answer is bowel perforation. Bowel perforation is the most serious complication of fiberoptic colonoscopy, with signs such as progressive abdominal pain, fever, chills, and tachycardia indicating advancing peritonitis. Although colonoscopic perforation is rare (0.03% to 0.7% incidence), it can lead to high mortality and morbidity rates. Viral gastroenteritis (
Choice
B) typically presents with symptoms like diarrhea, nausea, vomiting, and abdominal cramps, but it is not the most immediate concern in this scenario. Colon cancer (
Choice
C) and diverticulitis (
Choice
D) are important conditions but are less likely to present acutely after colonoscopy compared to bowel perforation.
Question 5 of 5
The nurse is preparing to administer an enteral feeding to a client via a nasogastric feeding tube. The most important action of the nurse is:
Correct Answer: A
Rationale: The most crucial action for the nurse when preparing to administer enteral feeding via a nasogastric tube is to verify the correct placement of the tube. Proper placement of the tube is vital to prevent complications such as aspiration into the lungs. The definitive methods to confirm the position of the nasogastric tube include visualization through an x-ray or aspirating stomach contents and checking their pH (usually pH 1 to 5). Aspirated stomach content can also be tested for bilirubin to confirm placement in the stomach.
Choice B, checking that the feeding solution matches the dietary order, is important for ensuring the correct nutrition is provided but is not as critical as verifying tube placement to prevent potential harm.
Choice C, aspirating gastric contents to determine the amount of the last feeding remaining in the stomach, is a common nursing practice but is not the most crucial action when compared to ensuring correct tube placement.
Choice D, ensuring that the feeding solution is at room temperature, is relevant for patient comfort and preventing thermal injury but is not as essential as confirming correct tube placement to prevent serious complications.