NCLEX-RN
Basic Adult Health Care NCLEX Heart Questions Questions
Extract:
Question 1 of 5
The nurse is assessing the home environment of an elderly client who is using crutches during the postoperative recovery phase after hip pinning. Which of the following would pose the greatest hazard to the client as a risk for falling at home?
Correct Answer: B
Rationale: Scatter rugs are a significant fall risk due to tripping hazards.
Question 2 of 5
Which of the following is a priority nursing diagnosis for the diabetic client who is taking insulin and has nausea and vomiting from a viral illness or influenza?
Correct Answer: A
Rationale: Nausea and vomiting from illness can lead to inadequate food intake, causing imbalanced nutrition, a priority due to the risk of hypoglycemia or ketoacidosis.
Question 3 of 5
The nurse is developing a plan of care for the client with viral hepatitis. The nurse should instruct the client to:
Correct Answer: A
Rationale: Adequate bed rest (
A) supports recovery in viral hepatitis by reducing metabolic demands. Increased fluids (
B) are helpful but secondary. High-protein (
C) or avoiding carbohydrates (
D) is not indicated.
Question 4 of 5
During the assessment of a client's mouth, the nurse notes the absence of saliva. The client has pain in the area of the ear. The client has been nothing-by-mouth (NPO) for several days because of the insertion of a nasogastric tube. Based on these findings, the nurse suspects that the client may be developing which of the following mouth conditions?
Correct Answer: C
Rationale: Parotitis, inflammation of the parotid gland, is suggested by the absence of saliva and ear pain, especially in a client who is NPO and dehydrated, which can impair salivary gland function. Stomatitis, oral candidiasis, and gingivitis typically present with different symptoms, such as mucosal inflammation, white patches, or gum bleeding.
Question 5 of 5
A nurse is instructing a client who had abdominal surgery that day to do deep-breathing exercises. In which order should the nurse teach the client to perform diaphragmatic breathing and coughing?
Order the Items
Source Container
Correct Answer: D,A,C,B
Rationale: The correct order is: splint the incision (
D) to reduce pain, inhale through the nose (
A) to expand lungs, exhale through pursed lips (
C) to control breathing, and cough deeply (
B) to clear secretions.