NCLEX-RN
Basic Adult Health Care NCLEX Heart Questions Questions
Extract:
Question 1 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 2 of 5
The nurse is reviewing the chart information for a client with increased ascites. The data include: temperature 37.2°C; heart rate 118; shallow respirations 26; blood pressure 128/76; and SpO2 89% on room air. Which action should receive priority by the nurse?
Correct Answer: D
Rationale: Low SpO2 (89%) and shallow respirations indicate respiratory compromise, likely from ascites pressing on the diaphragm. Raising the head of the bed (
D) improves breathing. Heart sounds (
A), blood cultures (
B), and paracentesis (
C) are secondary.
Question 3 of 5
Four days after surgery for internal fixation of a C3 to C4 fracture, a nurse is moving a client from the bed to the wheelchair. The nurse is checking the wheelchair for correct features for this client. Which of the following features of the wheelchair are appropriate for the needs of this client?
Correct Answer: B,D,E
Rationale: A high back and headrest provide neck stability, firm cushions prevent pressure ulcers, and a breath-controlled chair accommodates limited upper extremity function post-C3-C4 injury. A low back or lower seat height could compromise stability or transfer safety.
Question 4 of 5
A client is being monitored for transient ischemic attacks. She is oriented, can open her eyes spontaneously, and follows commands. What is her Glasgow Coma Scale score?
Correct Answer: 15
Rationale: The Glasgow Coma Scale assesses eye opening (4 for spontaneous), verbal response (5 for oriented), and motor response (6 for following commands). The client's score is 4 + 5 + 6 = 15.
Question 5 of 5
A client with Ménière'sdisease continues to have disabling attacks of vertigo and elects to have a labyrinthectomy. A priority nursing diagnosis for the client before surgery is:
Correct Answer: B
Rationale: Risk for injury related to vertigo is the priority due to the high risk of falls and accidents during vertigo attacks, which is a significant concern pre-surgery.