NCLEX-RN
Basic Adult Health Care NCLEX Heart Questions Questions
Extract:
Question 1 of 5
An 80-year-old client had spinal anesthesia for a transurethral resection of the prostate and received 4,000 mL of room temperature isotonic bladder irrigation. He now has continuous irrigation through a three-way indwelling urinary catheter. Which postoperative nursing intervention is most important to include in his plan of care?
Correct Answer: B
Rationale: Room-temperature irrigation can cause hypothermia, especially in an elderly client. Covering with warm blankets is the most important intervention to maintain normothermia.
Question 2 of 5
A client who has undergone a mastectomy is worried about her body image and its impact on her sexual relationship. The nurse should suggest:
Correct Answer: A
Rationale: Wearing a prosthesis can help the client feel more confident about her body image during intimate moments, supporting her sexual relationship.
Question 3 of 5
A client's chest tube is to be removed by the physician. Which of the following items should the nurse have ready to be placed directly over the wound when the chest tube is removed?
Correct Answer: D
Rationale: Petroleum gauze creates an airtight seal over the chest tube site, preventing air entry into the pleural space. Other dressings are less occlusive.
Question 4 of 5
A very elderly, drowsy client with fragile skin is being transferred from the surgery cart to the bed. How should the nurse plan to direct the transfer to prevent skin shearing?
Correct Answer: B
Rationale: Using a drawsheet with two people (one per side) and one at the head minimizes skin shearing by providing support and controlled movement, suitable for a drowsy elderly client.
Question 5 of 5
The nurse is completing a health assessment of a 42-year-old female with suspected Graves' disease. The nurse should assess this client for:
Correct Answer: B
Rationale: Graves' disease, the most common type of thyrotoxicosis, is a state of hypermetabolism. The increased metabolic rate generates heat and produces tachycardia and fine muscle tremors. Anorexia is associated with hypothyroidism. Loss of weight, despite a good appetite and adequate caloric intake, is a common feature of hyperthyroidism. Cold skin is associated with hypothyroidism.