NCLEX-RN
Physiological Adaptation NCLEX RN Questions
Extract:
Question 1 of 5
The nurse is caring for a client who has shortness of breath, +2 pitting edema bilaterally of the lower extremities, crackles in the bases of the lungs, and a weight gain of 7 pounds in 1 week. The nurse administers furosemide 40 mg IV as ordered. Which would the nurse anticipate to indicate that the furosemide was effective? Select all that apply.
Correct Answer: B,C,D,E
Rationale: Furosemide effectiveness is indicated by reduced edema (
B), less shortness of breath (
C), increased urine output (
D), and decreased crackles (E). Worsened edema (
A) indicates ineffectiveness.
Question 2 of 5
The nurse is caring for a client who has shortness of breath, +2 pitting edema bilaterally of the lower extremities, crackles in the bases of the lungs, and a weight gain of 7 pounds in 1 week. The nurse administers furosemide 40 mg IV as ordered. Which would the nurse anticipate to indicate that the furosemide was effective? Select all that apply.
Correct Answer: B,C,D,E
Rationale: Furosemide effectiveness is indicated by reduced edema (
B), less shortness of breath (
C), increased urine output (
D), and decreased crackles (E). Worsened edema (
A) indicates ineffectiveness.
Question 3 of 5
The nurse is preparing to extubate a client. Arrange in order of priority the actions that the nurse should take to perform this procedure.
Order the Items
Source Container
Correct Answer: B,F,A,E,G,C,D
Rationale: Explain procedure (
B) to prepare client,(F) set up oxygen/emergency equipment , hyperoxygenate (
A), suction (E), deflate cuff/remove tube (G), instruct to cough (
C), apply oxygen (
D), teach spirometer use
Question 4 of 5
The ED nurse has admitted a client who is homeless and was found unresponsive in the street during below freezing temperatures. The client is diagnosed with severe hypothermia. The nurse should implement which measures for this client? Select all that apply.
Correct Answer: A,C,D,F
Rationale: Heating blanket (
A), assessing consciousness (
C), supine position (
D), and preparing for CPR (F) are appropriate for severe hypothermia. Oral temperature (
B) is inaccurate, and vigorous massage (E) risks tissue damage.
Question 5 of 5
The nurse is caring for a client who just returned from a right mastectomy. Which position does the nurse anticipate for the client?
Correct Answer: C
Rationale: Semi-Fowler's with the affected arm supported (
C) promotes comfort and reduces lymphedema risk post-mastectomy. High Fowler's (
A), flat (
B), and reverse Trendelenburg's (
D) are less optimal.