NCLEX RN FINAL EXAM 2024 QUESTIONS AND ANSWERS WITH RATIONALE. A GRADED

NCLEX RN FINAL EXAM 2024 QUESTIONS AND ANSWERS WITH RATIONALE. A GRADED Question 1: A nurse is caring for a client with heart failure. Which assessment finding should the nurse recognize as a sign of worsening heart failure? A) Decreased respiratory rate B) Increased blood pressure C) Weight gain of 2 pounds in 24 hours D) Decreased edema in the lower extremities Answer: C) Weight gain of 2 pounds in 24 hours Explanation: Weight gain is an important indicator of fluid retention in heart failure patients. A weight gain of 2 pounds in 24 hours can indicate fluid overload, worsening heart failure, and inadequate response to treatment. It is crucial for the nurse to monitor daily weights in heart failure patients to detect early signs of fluid retention. Question 2: A client is admitted with diabetic ketoacidosis (DKA). Which intervention should the nurse prioritize? A) Administering regular insulin B) Monitoring blood glucose every 8 hours C) Encouraging the client to eat a high-fat diet D) Providing sodium bicarbonate IV Answer: A) Administering regular insulin Explanation: The priority in DKA management is to lower blood glucose levels and reverse ketoacidosis. Regular insulin is the treatment of choice to decrease blood glucose levels. Blood glucose should be monitored more frequently (typically every hour) in DKA. A high-fat diet is contraindicated in DKA, and sodium bicarbonate is generally not recommended due to the risk of paradoxical cerebral acidosis.