NCLEX-RN
Basic Adult Health Care NCLEX Heart Questions Questions
Extract:
Question 1 of 5
When monitoring a client who is receiving t-PA, the nurse should have resuscitation equipment available because reperfusion of the cardiac tissue can result in which of the following?
Correct Answer: A
Rationale: Reperfusion from t-PA can cause arrhythmias due to myocardial irritability as blood flow is restored, necessitating resuscitation equipment.
Question 2 of 5
A client with malignant melanoma asks the nurse about the prognosis. The nurse should base a response that informs the client that the prognosis depends on:
Correct Answer: D
Rationale: Melanoma prognosis primarily depends on lesion thickness (Breslow depth), as thicker lesions indicate deeper invasion and worse outcomes.
Question 3 of 5
The nurse devises a teaching plan for the client with aplastic anemia. Which of the following is the most important concept to teach for health promotion and maintenance?
Correct Answer: B
Rationale: Aplastic anemia is characterized by bone marrow failure, leading to low blood cell counts and increased risk of infection due to neutropenia. The most important health promotion strategy is to avoid exposure to infections, as infections can be life-threatening in these clients. While nutrition, stress management, and sleep are important, infection prevention is the priority.
Question 4 of 5
To approach a deaf client, the nurse should do which of the following first?
Correct Answer: D
Rationale: Getting the client's attention first (e.g., by waving or tapping gently) ensures effective communication with a deaf client, as they may not hear auditory cues.
Question 5 of 5
Four days after surgery for internal fixation of a C3 to C4 fracture, a nurse is moving a client from the bed to the wheelchair. The nurse is checking the wheelchair for correct features for this client. Which of the following features of the wheelchair are appropriate for the needs of this client?
Correct Answer: B,D,E
Rationale: A high back and headrest provide neck stability, firm cushions prevent pressure ulcers, and a breath-controlled chair accommodates limited upper extremity function post-C3-C4 injury. A low back or lower seat height could compromise stability or transfer safety.