NCLEX-RN
Basic Adult Health Care NCLEX Heart Questions Questions
Extract:
Question 1 of 5
The nurse is unable to palpate the client's left pedal pulses. Which of the following actions should the nurse take next?
Correct Answer: C
Rationale: If pedal pulses are not palpable, the next step is to use a Doppler ultrasound device to detect blood flow, as pulses may be weak due to PVD or other causes. Auscultation is not used for peripheral pulses, calling the physician is premature, and inspection is less specific than Doppler assessment.
Question 2 of 5
Which of the following physical assessment findings are normal for a client with advanced chronic obstructive pulmonary disease (COPD)?
Correct Answer: A
Rationale: Advanced COPD causes air trapping, increasing anteroposterior chest diameter (barrel chest). Neck muscles may hypertrophy from respiratory effort. Neck veins may distend, and chest excursions decrease due to lung hyperinflation.
Question 3 of 5
After surgery for an ileal conduit, the nurse should closely assess the client for the occurrence of which of the following complications related to pelvic surgery?
Correct Answer: A,B
Rationale: Peritonitis and thrombophlebitis are significant complications of pelvic surgery like an ileal conduit, due to potential infection or vascular issues. 'Ingestes' appears to be a typo and is not a recognized complication.
Question 4 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
Question 5 of 5
A client says, 'I hate the idea of being an invalid after they cut off my leg.' Which of the following would be the nurse's most therapeutic response?
Correct Answer: B
Rationale: Encouraging the client to express feelings fosters coping and addresses emotional concerns.