NCLEX PN COMPREHENSIVE 2023 FORM C

NCLEX PN COMPREHENSIVE 2023 FORM C

ACTUAL EXAM CONTAINS 160 QUESTIONS AND

CORRECT DETAILED ANSWERS WITH

RATIONALES|ALREADY GRADED A+

NCLEX PN COMPREHENSIVE FORM C

The nurse is collecting data on a client with a diagnosis of right-sided heart failure.The nurse should expect to note which specific characteristic of this condition?

• Dyspnea
• Hacking cough
• Dependent edema
• Crackles on lung auscultation
• Dependent edema

Rationale:

Right-sided heart failure is characterized by signs of systemic congestion that occur as a result of right ventricular failure, fluid retention, and pressure buildup in the venous system. Edema develops in the lower legs and ascends to the thighs and abdominal wall. Other characteristics include jugular (neck vein) congestion, enlarged liver and spleen, anorexia and nausea, distended abdomen, swollen hands and fingers, polyuria at night, and weight gain. Left-sided heart failure produces pulmonary signs. These include dyspnea, crackles on lung auscultation, and a hacking cough. 1 / 4

The nurse is checking the neurovascular status of a client who returned to the surgical nursing unit 4 hours ago after undergoing an aortoiliac bypass graft. The affected leg is warm, and the nurse notes redness and edema. The pedal pulse is palpable and unchanged from admission. The nurse interprets that the neurovascular status is which?

• Moderately impaired, and the surgeon should be called
• Normal, caused by increased blood flow through the leg
• Slightly deteriorating, and should be monitored for another hour
• Adequate from an arterial approach, but venous complications are arising
• Normal, caused by increased blood flow through the leg

Rationale:

An expected outcome of surgery is warmth, redness, and edema in the surgical extremity caused by increased blood flow. Options 1, 3, and 4 are incorrect.

A client with a diagnosis of rapid rate atrial fibrillation asks the nurse why the health care provider is going to perform carotid massage. The nurse responds that this procedure may stimulate which?

• Vagus nerve to slow the heart rate
• Vagus nerve to increase the heart rate
• Diaphragmatic nerve to slow the heart rate 2 / 4

• Diaphragmatic nerve to increase the heart rate
• Vagus nerve to slow the heart rate

Rationale:

Carotid sinus massage is one maneuver used for vagal stimulation to decrease a rapid heart rate and possibly terminate a tachydysrhythmia. The other maneuvers are the Valsalva maneuver of inducing the gag reflex and asking the client to strain or bear down. Medication therapy is often needed as an adjunct to keep the rate down or maintain the normal rhythm.

A client is admitted to the hospital with possible rheumatic endocarditis. The nurse should check for a history of which type of infection?

• Viral infection
• Yeast infection
• Streptococcal infection
• Staphylococcal infection
• Streptococcal infection

Rationale:

Rheumatic endocarditis, also called rheumatic carditis, is a major indicator of rheumatic fever, which is a complication of infection with group A β-hemolytic streptococcal infections. It is frequently triggered by streptococcal pharyngitis.Options 1, 2, and 4 are incorrect.

• / 4

A client has an Unna boot applied for treatment of a venous stasis leg ulcer. The nurse notes that the client's toes are mottled, and cool and the client verbalizes some numbness and tingling of the foot. Which interpretation should the nurse make of these findings?

• The boot has not yet dried.
• The boot is controlling leg edema.
• The boot is impairing venous return.
• The boot has been applied too tightly.
• The boot has been applied too tightly.

Rationale:

An Unna boot that is applied too tightly can cause signs of arterial occlusion. The nurse assesses the circulation in the foot and teaches the client to do the same. The other options are incorrect interpretations.

A client with angina complains that the anginal pain is prolonged and severe and occurs at the same time each day, most often in the morning. On further data collection, the nurse notes that the pain occurs in the absence of precipitating factors. How should the nurse best describe this type of anginal pain?

• Stable angina
• Variant angina
• Unstable angina
• Nonanginal pain
• / 4