NCLEX-RN
Basic Adult Health Care NCLEX Heart Questions Questions
Extract:
Question 1 of 5
The nurse observes that an older female has small to moderate, distended and tortuous veins running along the inner aspect of her lower legs. The nurse should:
Correct Answer: D
Rationale: Distended, tortuous veins suggest varic varicose veins. Avoiding prolonged standing reduces venous pooling and symptom progression. Applying compression devices requires a prescription, contacting a physician is premature, and foot ulcers are not indicated by the description.
Question 2 of 5
Which of the following skin preparations would be best to apply around the client's colostomy?
Correct Answer: A
Rationale: Karaya is a natural skin barrier that protects the skin around the stoma from irritation and is commonly used in ostomy care. Petroleum jelly is not suitable as it can interfere with adhesion of the ostomy appliance, and antiseptic cream is not typically used for routine skin protection around a stoma. CN: Physiological adaptation; CL: Apply
Question 3 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 4 of 5
A client post-extracorporeal shock wave lithotripsy should report:
Correct Answer: B
Rationale: Severe flank pain may indicate a complication like hematoma or obstruction.
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.