NUR FUNDAMENTAL NCLEX-RN QUESTIONS AND ANSWERS/RATED A

NCLEX-RN Questions with Rationale Physiological Adaptation Question 1: The nurse reviews the chart of a client following cardiac catheterization and notes the ejection fraction is 0.3 or 30% of normal. The nurse would expect the plan of care to focus on: 1. Management of pain from angina episodes. 2. Inability to perform self-care caused by fatigue. 3. Impaired motor and sensory function in extremities. 4. Reducing risk of stroke from hypertension. Key words: EF, 30% of normal, plan of care Correct answer is: Inability to perform self-care caused by fatigue Rationale for correct answer: when someone’s EF is less than normal, it means the heart is not perfusing as much blood in each pump as it should, which can cause fatigue and inability to perform self-care Rationale for incorrect answers: A. EF is measured by cardiac output, not CAD B. impaired motor function and sensory function in extremities is a neurological issue C. A decreased EF would cause hypotension, not HTN Question 2: A 10-year-old child with asthma is treated for acute exacerbation in the emergency department. The nurse caring for the child should monitor for which sign, knowing that it indicates a worsening of the condition? 1. Warm and dry skin. 2. Decreased wheezing and lethargic. 3. Heart rate 100 beats per minute and respiratory rate of 30 breaths per minute. 4. Clear lungs and able to speak in full sentences. Key words: asthma, signs, worsening Correct answer is: decreased wheezing and lethargic Rationale for correct answer: asthma is an inflammatory disease of the respiratory system, so decreased wheezing would mean that the patient’s airway is constricting even more, making it harder for them to breathe Rationale for incorrect answers: A. Since the child’s ability to breathe is decreasing, their skin would not be warm and dry, but cold and diaphoretic. Warm and dry would mean the child is improving B. This is a high heart rate, and 30 breaths per minute could mean that the child is gasping for air, but this is not as concerning as decreased wheezing and lethargic C. Clear lungs and able to speak in full sentences means the child is getting better This study source was downloaded by from CourseH on :11:49 GMT -06:00 NCLEX-RN Questions with Rationale Physiological Adaptation Question 3: The nurse assigned a client with global aphasia to the licensed practical nurse (LPN). The nurse validates the LPN understands global aphasia. Which response best describes this problem? 1. It is the inability to use or comprehend language and symbols. 2. It is a result of impaired hearing and speech. 3. It is as if a foreign language is being spoken. 4. It is the inability to express words or name objects Key words: global aphasia, LPN, response Correct answer is: the inability to use or comprehend language and symbols Rationale for correct answer: global means all so all aspects of speech are affected Rationale for incorrect answers: 2. There are no problems with their hearing, making this answer wrong 3. their mouth cannot form words correctly, not speak a completely different language 4. they likely can name objects but do not have the ability to form the words Question 4: A client with a deteriorating mental status after suffering a stroke has a rectal temperature of 102.3ºF (39.1ºC). For which reason should a nurse initiate interventions to bring the temperature to a normal level? 1. A normal temperature will strengthen the client’s immune system against infection. 2. Hyperthermia lowers the incidence of mortality. 3. A normal temperature will decrease the score on the Glasgow coma scale. 4. Hyperthermia increases the likelihood of a larger area of the brain infarct. Key words: deteriorating mental status, stroke, 102.3, initiate interventions Correct answer is: Hyperthermia increases the likelihood of a larger area of the brain infarct Rationale for correct answer: hyperthermia can have damaging effects on the brain, especially in someone who recently had a stroke Rationale for incorrect answers: 1. A high-grade fever doesn’t help strengthen the body’s immune system 2. Hyperthermia can cause death 3. Temperature isn’t something measured for the Glasgow coma scale, and in the Glasgow coma scale you want a higher This study source was downloaded by from CourseH on :11:49 GMT -06:00 NCLEX-RN Questions with Rationale Physiological Adaptation Question 5: The nurse is reviewing the chart information for a client with increased ascites. The data include: temperature 99.0 F (37.2 C); heart rate 118; shallow respirations 26; blood pressure 128/76; and oxygen saturation of 89% on room air. Which action should receive priority by the nurse? 1. Assess heart sounds. 2. Obtain an order for blood cultures. 3. Prepare for a paracentesis. 4. Raise the head of the bed. Key words: ascites, 99F, 118bpm, shallow resp 26, 128/76, ox sat 89% RA, priority action Correct answer is: raise the head of the bed Rationale for correct answer: laying down is putting pressure from the fluid accumulation in the stomach against the diaphragm which is making it harder for the patient to breathe Rationale for incorrect answers: 1. the problem is not about the heart, but the low oxygen saturation. 2. you don’t need blood cultures for ascites