NCLEX-RN
Assessment of a Patient Questions
Extract:
Question 1 of 5
The nurse is preparing a woman in labor for an amniotomy. Which priority data should the nurse assess before the procedure?
Correct Answer: A
Rationale: Fetal well-being must be confirmed before and after amniotomy. Fetal heart rate should be checked by Doppler or with the application of the external fetal monitor. Although maternal vital signs may be assessed, fetal heart rate is the priority. A fetal scalp sampling cannot be done when the membranes are intact.
Question 2 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.
Question 3 of 5
A client diagnosed with cirrhosis of the liver is receiving oral triamterene daily. Which sign/symptom would indicate to the nurse that the client is experiencing an adverse effect of the medication?
Correct Answer: D
Rationale: Triamterene is a potassium-retaining diuretic. Adverse effects include hyperkalemia, dehydration, hyponatremia, and lethargy. Although the concern with most diuretics is hypokalemia, this is a potassium-retaining medication, which means that the concern with the administration of this medication is hyperkalemia. Other effects include nausea, vomiting, cramping, diarrhea, headache, ataxia, drowsiness, confusion, and fever.
Question 4 of 5
Which assessment finding should the nurse expect to note in the child hospitalized with a diagnosis of nephrotic syndrome?
Correct Answer: D
Rationale: Clinical manifestations associated with nephrotic syndrome include edema, anorexia, fatigue, and abdominal pain from the presence of extra fluid in the peritoneal cavity. Diarrhea caused by the edema of the bowel occurs and may cause decreased absorption of nutrients. Increased weight from fluid buildup and a normal blood pressure are noted.
Question 5 of 5
The nurse is preparing a woman in labor for an amniotomy. Which priority data should the nurse assess before the procedure?
Correct Answer: A
Rationale: Fetal well-being must be confirmed before and after amniotomy. Fetal heart rate should be checked by Doppler or with the application of the external fetal monitor. Although maternal vital signs may be assessed, fetal heart rate is the priority. A fetal scalp sampling cannot be done when the membranes are intact.