NCLEX-RN
Basic Adult Health Care NCLEX Heart Questions Questions
Extract:
Question 1 of 5
An 82-year-old female has several ecchymotic areas on her left arm. The nurse should further assess the client for:
Correct Answer: C
Rationale: Aging increases capillary fragility and permeability, leading to easy bruising (ecchymosis). While elder abuse is possible, capillary fragility is the most likely cause in this context.
Question 2 of 5
Which of the following is the most common initial manifestation of acute renal failure?
Correct Answer: D
Rationale: Oliguria, reduced urine output, is the most common initial sign of acute renal failure due to impaired kidney filtration.
Question 3 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 4 of 5
On the evening of surgery for total knee replacement, a client wants to get out of bed. To safely assist the client the nurse should do which of the following?
Correct Answer: D
Rationale: A knee immobilizer ensures stability and safety during initial transfers post-surgery.
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.