NCLEX Questions and Rationales Study Guide

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, 31. The wife of a client calls the clinic and tells the nurse her husband is having chest pain but
won’t go to the hospital. Which action should the nurse implement first?

1. Instruct the wife to call 911 immediately.
2. Tell the wife to have the client chew an aspirin.
3. Ask the wife what the client had to eat recently.
4. Request the husband talk to the clinic nurse.



32. The home health (HH) nurse received phone messages from the agency secretary.
Which client should the nurse phone first?

1. The client diagnosed with hypertension who is reporting a BP of 148/92.
2. The client diagnosed with cardiomyopathy who has a pulse oximeter reading of 93%.
3. The client diagnosed with congestive heart failure who has edematous feet.
4. The client diagnosed with chronic atrial fibrillation who is having chest pain.


33. The client is diagnosed with end-stage congestive heart failure. The nurse finds the client lying in
bed, short of breath, unable to talk, and with buccal cyanosis. Which intervention should the nurse
implement first?

1. Assist the client to a sitting position.
2. Assess the client’s vital signs.
3. Call 911 for the paramedics.
4. Auscultate the client’s lung sounds.




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