NCLEX-RN
Basic Adult Health Care NCLEX Heart Questions Questions
Extract:
Question 1 of 5
The nurse should do which of the following to decrease a female client's anxiety about being placed in the lithotomy position for surgery?
Correct Answer: B
Rationale: Determining the client's specific concerns about the lithotomy position allows the nurse to address her anxiety directly, promoting trust and tailored reassurance.
Question 2 of 5
An 80-year-old client had spinal anesthesia for a transurethral resection of the prostate and received 4,000 mL of room temperature isotonic bladder irrigation. He now has continuous irrigation through a three-way indwelling urinary catheter. Which postoperative nursing intervention is most important to include in his plan of care?
Correct Answer: B
Rationale: Room-temperature irrigation can cause hypothermia, especially in an elderly client. Covering with warm blankets is the most important intervention to maintain normothermia.
Question 3 of 5
A nurse is instructing a client who had abdominal surgery that day to do deep-breathing exercises. In which order should the nurse teach the client to perform diaphragmatic breathing and coughing?
Order the Items
Source Container
Correct Answer: D,A,C,B
Rationale: The correct order is: splint the incision (
D) to reduce pain, inhale through the nose (
A) to expand lungs, exhale through pursed lips (
C) to control breathing, and cough deeply (
B) to clear secretions.
Question 4 of 5
How often should the postoperative client's temperature be assessed during the first 24 hours after surgery?
Correct Answer: B
Rationale: Assessing temperature every 4 hours in the first 24 hours detects fever early, indicating potential infection or other complications.
Question 5 of 5
A very elderly, drowsy client with fragile skin is being transferred from the surgery cart to the bed. How should the nurse plan to direct the transfer to prevent skin shearing?
Correct Answer: B
Rationale: Using a drawsheet with two people (one per side) and one at the head minimizes skin shearing by providing support and controlled movement, suitable for a drowsy elderly client.