NCLEX-RN
Basic Adult Health Care NCLEX Heart Questions Questions
Extract:
Question 1 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 2 of 5
The nurse is administering packed red blood cells (PRBCs) to a client. The nurse should first:
Correct Answer: D
Rationale: The nurse should stay with the client during the first 15 minutes of a blood transfusion, as this is the most likely time for a transfusion reaction to occur. Close monitoring allows for immediate intervention if a reaction is detected. Discontinuing the IV is only done if a reaction occurs, PRBCs should not be administered via a 20-gauge needle (a larger gauge is needed), and dextrose solutions are incompatible with PRBCs.
Question 3 of 5
A client who has undergone a mastectomy is worried about her body image and its impact on her sexual relationship. The nurse should suggest:
Correct Answer: A
Rationale: Wearing a prosthesis can help the client feel more confident about her body image during intimate moments, supporting her sexual relationship.
Question 4 of 5
A client with deep vein thrombosis suddenly develops dyspnea, tachypnea, and chest discomfort. What should the nurse do first?
Correct Answer: D
Rationale: Sudden dyspnea, tachypnea, and chest discomfort suggest a pulmonary embolism, a medical emergency. Contacting the physician first ensures rapid intervention. Elevating the bed, encouraging coughing, or auscultating lungs delays critical treatment.
Question 5 of 5
A client who is recovering from a bilateral adrenalectomy has a patient-controlled analgesia (PCA) system with morphine sulfate. Which of the following actions is a priority nursing intervention for the client?
Correct Answer: C
Rationale: Regularly evaluating pain control ensures adequate relief while monitoring for side effects, a priority in PCA management.