NCLEX-RN
Basic Adult Health Care NCLEX Heart Questions Questions
Extract:
Question 1 of 5
The nurse is preparing to hang a new TPN bag. Which step is essential to prevent infection?
Correct Answer: B
Rationale: Verifying the TPN solution with another nurse ensures accuracy and prevents errors that could lead to infection or other complications. Clean gloves are insufficient (sterile technique is needed), tubing change frequency varies, and TPN is typically given via a central line. CN: Safety and infection control; CL: Synthesize
Question 2 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 3 of 5
Which of the following nursing interventions would promote effective airway clearance in a client with acute respiratory distress?
Correct Answer: D
Rationale: Suctioning clears secretions when coughing is ineffective in ARDS, maintaining airway patency. Oxygen delivery, turning, and sedatives are supportive but less direct for airway clearance.
Question 4 of 5
A client with a spinal cord injury is at risk for pressure ulcers. Which nursing intervention is most effective?
Correct Answer: D
Rationale: Turning every 2 hours redistributes pressure, preventing ulcer formation in immobilized clients.
Question 5 of 5
A client is admitted with a 6.5-cm thoracic aneurysm. The nurse records fi ndings from the initial assessment in the client’s chart, as shown below. At 10:30 a.m., the client complains of sharp midchest pain after having a bowel movement. What should the nurse do first?
Correct Answer: A
Rationale: The size of the thoracic aneurysm is rather large, so the nurse should anticipate rupture. A sudden incidence of pain may indicate leakage or rupture. The blood pressure and heart rate will provide useful information in assessing for hypovolemic shock. The nurse needs more data before initiating other interventions. After assessment of vital signs, neurologic status, and pain, the nurse can then contact the physician. Administering lactated Ringer’s solution would require a physician’s order