NCLEX-RN
NCLEX RN Practice Questions Quizlet Questions
Extract:
Question 1 of 5
During an assessment of a client with cardiomyopathy, the nurse finds that the systolic blood pressure has decreased from 145 to 110 mm Hg and the heart rate has risen from 72 to 96 beats per minute, and the client complains of periodic dizzy spells. The nurse instructs the client to:
Correct Answer: D
Rationale: In this scenario, the client with cardiomyopathy is exhibiting signs of orthostatic hypotension, which is characterized by a significant drop in systolic blood pressure (>15 mm Hg) and an increase in heart rate (>15%), along with dizziness. These symptoms suggest volume depletion, inadequate vasoconstrictor mechanisms, and autonomic insufficiency. The appropriate nursing intervention in this case is to force fluids and reassess blood pressure to address the underlying issue of volume depletion and improve hemodynamic stability.
Choices A, B, and D are incorrect because increasing fluids high in protein, restricting fluids, or limiting fluids to non-caffeine beverages are not appropriate actions for a client experiencing orthostatic hypotension and signs of volume depletion.
Question 2 of 5
A healthcare provider calls a physician with the concern that a patient has developed a pulmonary embolism. Which of the following symptoms has the healthcare provider most likely observed?
Correct Answer: B
Rationale: The correct answer is 'The patient suddenly complains of chest pain and shortness of breath.' Typical symptoms of pulmonary embolism include chest pain, shortness of breath, and severe anxiety. The physician should be notified immediately. Clinical signs and symptoms for pulmonary embolism are nonspecific; therefore, patients suspected of having pulmonary embolism"?because of unexplained dyspnea, tachypnea, or chest pain or the presence of risk factors for pulmonary embolism"?must undergo diagnostic tests until the diagnosis is ascertained or eliminated or an alternative diagnosis is confirmed.
Choices A, C, and D describe symptoms that are not typically associated with a pulmonary embolism, making them incorrect.
Question 3 of 5
A 28-year-old male has been found wandering around in a confusing pattern. The male is sweaty and pale. Which of the following tests is most likely to be performed first?
Correct Answer: A
Rationale: In a 28-year-old male presenting with confusion, sweating, and pallor, the most likely cause is hypoglycemia, especially with no mention of trauma or infection.
Therefore, the initial test to be performed should be a blood sugar check to rule out low blood sugar levels. Checking blood sugar levels is crucial in such a scenario as hypoglycemia can lead to altered mental status. A CT scan (choice
B) is not typically the initial test for altered mental status without any focal neurological signs or head trauma. Blood cultures (choice
C) are more relevant in cases suspected of infection, which is not a primary concern in this scenario. Arterial blood gases (choice
D) may be considered later if there are concerns about respiratory status or acid-base disturbances, but in this case, checking the blood sugar level is the most immediate and appropriate action.
Question 4 of 5
Which of the following conditions most commonly causes acute glomerulonephritis?
Correct Answer: B
Rationale: Acute glomerulonephritis is most commonly caused by the immune response to a prior upper respiratory infection with group A Streptococcus. Glomerular inflammation occurs about 10-14 days after the infection, resulting in scant, dark urine and retention of body fluid. Periorbital edema and hypertension are common signs at diagnosis.
Question 5 of 5
A thirty-five-year-old male has been an insulin-dependent diabetic for five years and now is unable to urinate. Which of the following would you most likely suspect?
Correct Answer: C
Rationale: In this case, the correct answer is autonomic neuropathy. Autonomic neuropathy affects the autonomic nerves, which control various bodily functions including the bladder. In diabetes, it can lead to bladder paralysis, resulting in symptoms like urgency to urinate and difficulty initiating urination. Atherosclerosis (choice
A) is a condition involving the hardening and narrowing of arteries, not directly related to the inability to urinate in this context. Diabetic nephropathy (choice
B) primarily affects the kidneys, leading to kidney damage, but does not typically cause urinary retention. Somatic neuropathy (choice
D) involves damage to sensory nerves, not the autonomic nerves responsible for bladder control, making it less likely to be the cause of the urinary issue described in the question.