NCLEX-RN
Assessment of a Patient Questions
Extract:
Question 1 of 5
The nurse is caring for a client diagnosed with acquired immunodeficiency syndrome (AIDS). Which sign/symptom indicates the presence of an opportunistic respiratory infection?
Correct Answer: B
Rationale: Fever and exertional dyspnea are signs of Pneumocystis jiroveci pneumonia, which is a common, life-threatening opportunistic infection that afflicts those with AIDS. Option 1 is not associated with respiratory infection. Options 3 and 4 are normal findings.
Question 2 of 5
A client is scheduled for an arteriogram using a radiopaque dye. What is the most important information the nurse should determine before the procedure to assure the client's safety?
Correct Answer: D
Rationale: Allergy to iodine or seafood is associated with allergy to the radiopaque dye that is used for medical imaging examinations. Informed consent is necessary because an arteriogram requires the injection of a radiopaque dye into the blood vessel. Although the remaining options are components of the preprocedure assessment, the risks of allergic reaction and possible anaphylaxis are the most critical to the client's safety.
Question 3 of 5
The nurse is monitoring a client who is receiving an oxytocin infusion for the induction of labor. The nurse should suspect water intoxication if which sign or symptom is noted?
Correct Answer: D
Rationale: Oxytocin is a uterine stimulant. During an oxytocin infusion, the woman is monitored closely for signs of water intoxication, including tachycardia, cardiac dysrhythmias, shortness of breath, nausea, and vomiting. The remaining options are not associated with water intoxication.
Question 4 of 5
A pregnant client diagnosed with diabetes mellitus arrives at the primary health care clinic for a follow-up visit. What best assessment should the nurse perform to assess insulin function?
Correct Answer: C
Rationale: In a pregnant client with diabetes mellitus, assessing insulin function is critical to ensure glycemic control and prevent complications. Testing urine for glucose and ketones is the best assessment, as it directly indicates whether insulin is effectively managing blood glucose levels (glucose in urine suggests hyperglycemia) and whether the client is at risk for ketoacidosis (ketones indicate fat metabolism due to insufficient insulin). Urine specific gravity reflects hydration status, not insulin function. Edema assessment is relevant for preeclampsia or fluid overload, not insulin function. Vital signs like blood pressure, pulse, and respirations provide general health information but are not specific to insulin function.
Question 5 of 5
The nurse is performing a cardiovascular assessment on a client. Which item should the nurse assess to obtain the best information about the client's left-sided heart function?
Correct Answer: A
Rationale: The client with heart failure may present different symptoms depending on whether the right or the left side of the heart is failing. The assessment of breath sounds provides information about left-sided heart function. Peripheral edema, hepatojugular reflux, and jugular vein distention are all signs of right-sided heart function.