NCLEX-RN
Basic Adult Health Care NCLEX Heart Questions Questions
Extract:
Question 1 of 5
After insertion of a nasoenteric tube, the nurse should place the client in which position?
Correct Answer: C
Rationale: The semi-Fowler's position facilitates drainage and decompression via the nasoenteric tube while promoting comfort and preventing aspiration. Supine, right side-lying, or upright positions are less effective for this purpose. CN: Physiological adaptation; CL: Synthesize
Question 2 of 5
The nurse is reviewing the chart information for a client with increased ascites. The data include: temperature 37.2°C; heart rate 118; shallow respirations 26; blood pressure 128/76; and SpO2 89% on room air. Which action should receive priority by the nurse?
Correct Answer: D
Rationale: Low SpO2 (89%) and shallow respirations indicate respiratory compromise, likely from ascites pressing on the diaphragm. Raising the head of the bed (
D) improves breathing. Heart sounds (
A), blood cultures (
B), and paracentesis (
C) are secondary.
Question 3 of 5
A client with bladder cancer reports fatigue and weight loss. The nurse should assess for:
Correct Answer: A
Rationale: Fatigue and weight loss in bladder cancer may indicate metastasis, as the disease progresses.
Question 4 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.
Question 5 of 5
After insertion of a nasoenteric tube, the nurse should place the client in which position?
Correct Answer: C
Rationale: The semi-Fowler's position facilitates drainage and decompression via the nasoenteric tube while promoting comfort and preventing aspiration. Supine, right side-lying, or upright positions are less effective for this purpose. CN: Physiological adaptation; CL: Synthesize