NCLEX-RN
NCLEX RN Physiological Adaptation Questions
Extract:
Question 1 of 5
The nurse is caring for a client with left-sided heart failure. Which assessment findings does the nurse anticipate for this client? Select all that apply.
Correct Answer: A,C,F
Rationale: Left-sided heart failure causes pulmonary congestion, leading to dyspnea (
A), dependent edema (
C), and crackles/wheezes (F). Spleen engorgement (
B), jugular vein distention (
D), and weak pulses (E) are more typical of right-sided failure.
Question 2 of 5
The nurse is performing the Glasgow coma scale on a client. The assessment is as follows: eye opening, to pain; motor response, localizes pain; verbal response, inappropriate words. The nurse interprets which score is correct for this client?
Correct Answer: A
Rationale: Glasgow Coma Scale: Eye opening to pain = 2, localizes pain = 5, inappropriate words = 2.
Total = 2 + 5 + 2 = 9 (
A).
Question 3 of 5
The nurse is caring for a client with left-sided heart failure. Which assessment findings does the nurse anticipate for this client? Select all that apply.
Correct Answer: A,C,F
Rationale: Left-sided heart failure causes pulmonary congestion, leading to dyspnea (
A), dependent edema (
C), and crackles/wheezes (F). Spleen engorgement (
B), jugular vein distention (
D), and weak pulses (E) are more typical of right-sided failure.
Question 4 of 5
The nurse is reviewing labs on a client with second- and third-degree burns from a house fire. Which abnormal lab value would the nurse expect to find with this client?
Correct Answer: D
Rationale: Burns cause cell damage, releasing potassium, leading to hyperkalemia (5.9 mEq/L,
D). pH 7.41 (
A), albumin 3.9 (
B), and hemoglobin 15 (
C) are within normal ranges.
Question 5 of 5
Which of the following is not a recommended preparation for electroconvulsive therapy (ECT)?
Correct Answer: D
Rationale: Anticonvulsants (
D) are not given before ECT, as seizures are therapeutic. Anticholinergics (
A), NPO/bath (
B), and consent (
C) are standard preparations.