Questions 107

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Basic Adult Health Care NCLEX Heart Questions Questions

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Question 1 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 2 of 5

An appropriate nursing intervention for a client with fatigue related to cancer treatment includes teaching the client to:

Correct Answer: C

Rationale: Conserving energy by limiting activities helps manage fatigue, a common side effect of cancer treatment, by balancing rest and activity.

Question 3 of 5

Which of the following is the best way for the nurse to begin the preoperative interview?

Correct Answer: C

Rationale: Introducing oneself while maintaining eye contact and sitting down establishes rapport and trust, creating a therapeutic environment for the interview. This approach prioritizes patient comfort and communication.

Question 4 of 5

A client is admitted for a revascularization procedure for arteriosclerosis in his left iliac artery. To promote circulation in the extremities, the nurse should:

Correct Answer: C

Rationale: Positioning the left leg at or below the body's horizontal plane promotes arterial blood flow to the extremity in arteriosclerosis, avoiding gravitational resistance. A firm mattress is irrelevant, warmth is beneficial but secondary, and leg raises may not be feasible pre-revascularization.

Question 5 of 5

Sublingual nitroglycerin tablets begin to work within 1 to 2 minutes. How should the nurse instruct the client to use the drug when chest pain occurs?

Correct Answer: C

Rationale: Standard protocol for sublingual nitroglycerin is one tablet every 5 minutes for up to three doses. If pain persists, the client should seek medical help.

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