NCLEX-RN
Basic Adult Health Care NCLEX Heart Questions Questions
Extract:
Question 1 of 5
The nurse is assisting a client with crutches to ascend stairs. Which instruction is correct?
Correct Answer: B
Rationale: Using the handrail on the unaffected side provides stability and safety while ascending stairs.
Question 2 of 5
The nurse is administering packed red blood cells (PRBCs) to a client. The nurse should first:
Correct Answer: D
Rationale: The nurse should stay with the client during the first 15 minutes of a blood transfusion, as this is the most likely time for a transfusion reaction to occur. Close monitoring allows for immediate intervention if a reaction is detected. Discontinuing the IV is only done if a reaction occurs, PRBCs should not be administered via a 20-gauge needle (a larger gauge is needed), and dextrose solutions are incompatible with PRBCs.
Question 3 of 5
A client who has been given cardiopulmonary resuscitation (CPR) is transported by ambulance to the hospital's emergency department, where the admitting nurse quickly assesses the client's condition. The most effective way to determine the effectiveness of CPR is noting whether the:
Correct Answer: D
Rationale: A systolic blood pressure of at least 80 mm Hg indicates effective CPR, as it reflects adequate circulation and perfusion.
Question 4 of 5
When monitoring a client who is receiving t-PA, the nurse should have resuscitation equipment available because reperfusion of the cardiac tissue can result in which of the following?
Correct Answer: A
Rationale: Reperfusion from t-PA can cause arrhythmias due to myocardial irritability as blood flow is restored, necessitating resuscitation equipment.
Question 5 of 5
The nurse devises a teaching plan for the client with aplastic anemia. Which of the following is the most important concept to teach for health promotion and maintenance?
Correct Answer: B
Rationale: Aplastic anemia is characterized by bone marrow failure, leading to low blood cell counts and increased risk of infection due to neutropenia. The most important health promotion strategy is to avoid exposure to infections, as infections can be life-threatening in these clients. While nutrition, stress management, and sleep are important, infection prevention is the priority.