NCLEX-RN
Basic Adult Health Care NCLEX Heart Questions Questions
Extract:
Question 1 of 5
The family of a client in hospice asks about stopping oral feedings. The nurse should explain that:
Correct Answer: A
Rationale: Stopping oral feedings in hospice can reduce discomfort from fluid overload or aspiration, aligning with comfort-focused care.
Question 2 of 5
A client is having a cataract removed and will use eyeglasses after the surgery. The nurse should develop a teaching plan that includes which of the following? Select all that apply.
Correct Answer: A,B,C
Rationale: The use of glasses following cataract surgery does not totally restore binocular vision. Glasses will cause images to appear larger and peripheral vision will be distorted; the client should look through the center of the glasses and turn his or her head to view objects in the periphery. The client should also use caution when walking or climbing stairs until he or she has adjusted to the change in vision. Staying out of the sun is not necessary, but dark glasses may be used to prevent photophobia.
Question 3 of 5
Which outcome is appropriate for a client with a traumatic brain injury?
Correct Answer: B
Rationale: Active participation in therapy is a realistic outcome for recovery in traumatic brain injury.
Question 4 of 5
A female receiving radiation therapy for lung cancer complains to the nurse that she is having difficulty sleeping. Which of the following nursing actions is most appropriate?
Correct Answer: B
Rationale: Assessing sleep patterns, amount of sleep, and bedtime rituals provides a comprehensive understanding of the client's insomnia, enabling tailored interventions.
Question 5 of 5
A client is admitted with a 6.5-cm thoracic aneurysm. The nurse records fi ndings from the initial assessment in the client’s chart, as shown below. At 10:30 a.m., the client complains of sharp midchest pain after having a bowel movement. What should the nurse do first?
Correct Answer: A
Rationale: The size of the thoracic aneurysm is rather large, so the nurse should anticipate rupture. A sudden incidence of pain may indicate leakage or rupture. The blood pressure and heart rate will provide useful information in assessing for hypovolemic shock. The nurse needs more data before initiating other interventions. After assessment of vital signs, neurologic status, and pain, the nurse can then contact the physician. Administering lactated Ringer’s solution would require a physician’s order