NCLEXUPDATEDQUESTIONSAND

NCLEXUPDATEDQUESTIONSAND

ANSWERSFORFINALEXAM2025Examsof Nursing Aclientisatriskforvasovagalattacksthatcausebradydysrhythmias.Thenursewouldtelltheclient toavoidwhichactionstopreventthisoccurrence?Selectallthatapply.

1.Applyingpressureontheeyes2.Raisingthearmsabovethehead3.Takingstoolsoftenersonadaily basis4.Bearingdownduringabowelmovement5.Simulatingagagreflexwhenbrushingtheteeth 1.Applyingpressureontheeyes2.Raisingthearmsabovethehead4.Bearingdownduringabowel movement5.Simulatingagagreflexwhenbrushingtheteeth Rationale:Vasovagalattacksorsyncopeoccurswhentheclientfaintsbecausethebodyoverreactsto certaintriggers.Thevasovagalsyncopetriggercausestheheartrateandbloodpressuretodrop suddenly.Thatleadstoreducedbloodflowtothebrain,causingtheclienttobrieflylose consciousness.Theclientatriskshouldbetaughttoavoidactionsthatstimulatethevagusnerve.Actionstoavoidincluderaisingthearmsabovethehead,applyingpressureoverthecarotidartery, applyingpressureovertheeyes,stimulatingagagreflexwhenbrushingtheteethorputtingobjects intothemouth,andbearingdownorstrainingduringabowelmovement.Takingstoolsoftenersisan importantmeasuretopreventthebearingdownandstrainingduringabowelmovement.Thenurseemployedinacardiacunitdeterminesthatwhichclientistheleastlikelytohavean implantedcardioverter-defibrillator(ICD)inserted?

1.Aclientwithsyncopalepisodesrelatedtoventriculartachycardia2.Aclientwithventricular dysrhythmiasdespitemedicationtherapy3.Aclientwithanepisodeofcardiacarrestrelatedto myocardialinfarction4.Aclientwith3episodesofcardiacarrestunrelatedtomyocardialinfarction 3.Aclientwithanepisodeofcardiacarrestrelatedtomyocardialinfarction Rationale:AnICDdetectsanddeliversanelectricalshocktoterminatelife-threateningepisodesof ventriculartachycardiaandventricularfibrillation.Thisdeviceisimplantedinclientswhoare consideredhighrisk,includingthosewhohavesyncopalepisodesrelatedtoventriculartachycardia, thosewhoarerefractivetomedicationtherapy,andthosewhohavesurvivedsuddencardiacdeath unrelatedtomyocardialinfarction.Thehomecarenurseisprovidinginstructionstoaclientwithanarterialischemiclegulcerabout homecaremanagementandself-caremanagement.Whichstatement,ifmadebytheclient,indicates aneedforfurtherinstruction?

1."Ineedtobesurenottogobarefootaroundthehouse."2."IfIcutmytoenails,Ineedtobesure thatIcutthemstraightacross."3."Itisallrighttoapplylanolintomyfeet,butIshouldn'tplaceit betweenmytoes."4."IneedtobesurethatIelevatemylegabovethelevelofmyheartforatleast anhoureveryday." 4."IneedtobesurethatIelevatemylegabovethelevelofmyheartforatleastanhoureveryday." 1 / 4

Rationale:Footcareinstructionsfortheclientwithperipheralarterialdiseasearethesameasthose foraclientwithdiabetesmellitus.Theclientwitharterialdisease,however,shouldavoidraisingthe legsabovetheleveloftheheartunlessinstructedtodosoaspartofanexerciseprogramorifvenous stasisisalsopresent.Theclientstatementsintheremainingoptionsarecorrectstatementsand indicatethattheteachinghasbeeneffective.Wehaveanexpert-writtensolutiontothisproblem!Aclientwhohasbeenexercisinginagymnasiumstopstomeasurehispulseandplaceshisfingers overbothcarotidarteriessimultaneously.Thenurseexercisingnearbyiscorrectwhencautioningthe clienttocheckthepulseononlyoneside,primarilyforwhichreason?

1.Itisunnecessarytousebothhands.2.Theclientcouldoccludethetrachea.3.Theheartrateand bloodpressurecoulddrop.4.Feelingdualpulsationsmayleadtoanincorrectmeasurement.

3.Theheartrateandbloodpressurecoulddrop.Rationale:Applyingpressuretobothcarotidarteriesatthesametimeiscontraindicated.Excess pressuretothebaroreceptorsinthecarotidvesselscouldcausetheheartrateandbloodpressureto dropreflexively.Inaddition,themanualpressurecouldinterferewiththeflowofbloodtothebrain, causingpossibledizzinessandsyncope.Althoughtheinformationintheremainingoptionsmaybe correct,thesearenottheprimaryreasons.Aclientisscheduledforacardiaccatheterizationusinganiodineagent.Whichassessmentismost criticalbeforetheprocedure?

1.Intakeandoutput2.Heightandweight3.Baselineperipheralpulserates4.Previousallergyto contrastagents 4.Previousallergytocontrastagents Rationale:Acardiaccatheterizationrequiresaninformedconsentbecauseitinvolvesinjectionofan iodine-basedcontrastagentintothebloodvessel.Theriskofallergicreactionandpossible anaphylaxisisaconcern,andthepresenceofallergiestopreviouslyreceivedcontrastagentsmustbe assessedbeforetheprocedure.Anantihistamineorcorticosteroidmaybegiventoaclientwitha positivehistoryortopreventareaction.Althoughtheremainingoptionsareaccurate,theyarenot themostcriticalpreprocedureassessments.Thenurseisassessingaclient'slegsforthepresenceofedema.Thenursenotesthattheclienthas mildpittingwithslightindentationandnoperceptibleswellingoftheleg.Howshouldthenurse defineanddocumentthisfinding?

1.1+edema2.2+edema3.3+edema4.4+edema 1.1+edema Rationale:Edemaisaccumulationoffluidintheintercellularspacesandisnotnormallypresent.To checkforedema,thenursewouldimprinthisorherthumbsfirmlyagainsttheanklemalleolusorthe tibia.Normally,theskinsurfacestayssmooth.Ifthepressureleavesadentintheskin,pittingedema ispresent.Itspresenceisgradedonthefollowing4-pointscale:1+,mildpitting,slightindentation,no perceptibleswellingoftheleg;2+,moderatepitting,indentationsubsidesrapidly;3+,deeppitting, 2 / 4

indentationremainsforashorttime,leglooksswollen;4+,verydeeppitting,indentationlastsalong time,legisveryswollen.Anemergencyroomnurseisperformingacardiovascularassessmentonaclient.Duringauscultation oftheheartsounds,thenursehearstheseabnormalsounds.Thenursesuspectsthattheclienthas whichcondition?

1.Atrialfibrillation2.Ventricularfibrillation3.Ventricularhypertrophy4.Leftbundlebranchblock 3.Ventricularhypertrophy Rationale:Thesoundthatthenursehearsisthefourthheartsound(S4).Diastolicfillingsoundsor gallops(S3,thethirdheartsound,andS4,thefourthheartsound)areproducedwhenthereis decreasedcomplianceofeitherorbothventricles.S3istermedventriculargallopandS4isreferredto asatrialgallop.TheS4soundoccursinthelaterstageofdiastole,duringatrialcontractionandactive fillingoftheventricles.Itisasoft,low-pitchedsoundandisheardimmediatelybeforeS1.Anatrial gallopisfoundmostcommonlyindisordersinvolvingincreasedstiffnessoftheventricle,suchas ventricularhypertrophy,ischemia,andfibrosis.S4isneverheardintheabsenceofatrialcontraction (atrialfibrillation).S4isbestheardwiththebellofthestethoscopeattheapex,withtheclientinthe supine,leftlateralposition.ThepresenceofS4mayalsoresultfrommyocardialinfarction, hypertension,hypertrophy,fibrosis,cardiomyopathy,corpulmonale,aorticstenosis,orpulmonic stenosis.Therefore,options1,2,and4areincorrect.Aclientisscheduledforacardiaccatheterizationtodiagnosetheextentofcoronaryarterydisease.Thenurseplaceshighestpriorityontellingtheclienttoreportwhichsensationduringtheprocedure?

1.Chestpain2.Urgetocough3.Warm,flushedfeeling4.Pressureattheinsertionsite 1.Chestpain Rationale:Theclientistaughttoreportchestpainoranyunusualsensationsimmediately.Theclient alsoistoldthatheorshemaybeaskedtocoughorbreathedeeplyfromtimetotimeduringthe procedure.Theclientisinformedthatawarm,flushedfeelingmayaccompanydyeinjectionandis normal.Becausealocalanestheticisused,theclientisexpectedtofeelpressureattheinsertionsite.Wehaveanexpert-writtensolutiontothisproblem!Thenursehascompletedaneducationalcoursecoveringfirst-degreeheartblock.Whichstatement bythenurseindicatesthatteachinghasbeeneffective?

1."PresenceofQwavesindicatesfirst-degreeheartblock."2."Tall,peakedTwavesindicatefirst- degreeheartblock."3."WidenedQRScomplexesindicatefirst-degreeheartblock."4."Prolonged, equalPRintervalsindicatefirst-degreeheartblock." 4."Prolonged,equalPRintervalsindicatefirst-degreeheartblock." Rationale:ProlongedandequalPRintervalsindicatefirst-degreeheartblock.ThedevelopmentofQ wavesindicatesmyocardialnecrosis.Tall,peakedTwavesmayindicatehyperkalemia.AwidenedQRS complexindicatesadelayinintraventricularconduction,suchasbundlebranchblock.An electrocardiogram(ECG)takenduringapainepisodeisintendedtocaptureischemicchanges,which alsoincludeSTsegmentelevationordepression. 3 / 4

Wehaveanexpert-writtensolutiontothisproblem!Cardiacmonitoringleadsareplacedonaclientwhoisatriskforprematureventricularcontractions (PVCs).WhichheartrhythmwillthenurseanticipateinthisclientifPVCsareoccurring?

1.APwaveprecedingeveryQRScomplex2.QRScomplexesthatareshortandnarrow3.InvertedP wavesbeforetheQRScomplexes4.Prematurebeatsfollowedbyacompensatorypause 4.Prematurebeatsfollowedbyacompensatorypause Rationale:PVCsareabnormalectopicbeatsoriginatingintheventricles.Theyarecharacterizedbyan absenceofPwaves,thepresenceofwideandbizarreQRScomplexes,andacompensatorypausethat followstheectopy.Wehaveanexpert-writtensolutiontothisproblem!Thehomehealthnurseisvisitingaclientwhohashadamechanicalvalvereplacementforsevere mitralvalvestenosis.Whichstatementbytheclientreflectsanunderstandingofspecific postoperativecareafterthissurgery?

1."Ineedtocountmypulseeveryday."2."Ihavetododeep-breathingexercisesevery2hours."3."I needtothrowawaymystraightrazorandbuyanelectricrazor."4."Ihavetogotothebathroom frequentlybecauseofmymedication." 3."Ineedtothrowawaymystraightrazorandbuyanelectricrazor." Rationale:Mechanicalvalvesrequirelong-termanticoagulationtopreventclotsfromformingonthe "foreign"objectimplantedintheclient'sbody.Anticoagulationtherapyrequiresclientstoavoidany traumaorpotentialmeansofcausingbleeding,suchastheuseofstraightrazors.Countingpulse, deep-breathingexercises,andgoingtothebathroomfrequentlyarenotspecificallyrelatedto postoperativecareafterprostheticmechanicalvalvereplacement.Thenurseidentifiesthataclientishavingoccasionalprematureventricularcontractions(PVCs)onthe cardiacmonitor.Thenursereviewstheclient'slaboratoryresultsanddeterminesthatwhichresult wouldbeconsistentwiththeobservation?

1.Serumchloridelevelof98mEq/L(98mmol/L)2.Serumsodiumlevelof145mEq/L(145mmol/L) 3.Serumcalciumlevelof10.5mg/dL(2.75mmol/L)4.Serumpotassiumlevelof2.8mEq/L(2.8mmol/L) 4.Serumpotassiumlevelof2.8mEq/L(2.8mmol/L) Rationale:Thenurseshouldchecktheclient'sserumlaboratorystudyresultsforhypokalemia.The clientmayexperiencePVCsinthepresenceofhypokalemiabecausethiselectrolyteimbalance increasestheelectricalinstabilityoftheheart.Thevaluesnotedintheremainingoptionsarenormal.Thehomecarenursehastaughtaclientwithaproblemofinadequatecardiacoutputabouthelpful lifestyleadaptationstopromotehealth.Whichstatementbytheclientbestdemonstratesan understandingoftheinformationprovided?

1."Iwilleatenoughdailyfibertopreventstrainingatstool."2."Iwilltrytoexercisevigorouslyto strengthenmyheartmuscle."3."Iwilldrink3000to3500mLoffluiddailytopromotegoodkidney

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