A male client is undergoing cardiac tests. He has been instructed to w

NCLEX RN Exam Questions

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Question 1 of 5.

A male client is undergoing cardiac tests. He has been instructed to wear a Holter monitor. The nurse knows she has included the appropriate information in her teaching when the client tells her:

A. He should remove the electrodes for bathing.'

B. Damage to his heart muscle will be recorded by the monitor.'

C. He is to keep a record of everything he does during the day.'

D. He is to refrain from activities that cause chest pain.'

Explanation: The client should leave the electrodes in place during the entire time the test is ordered. He should not even remove the electrodes for bathing. The Holter monitor will record cardiac electrical activity but will not record damage to his myocardium. The client should keep a record of all of his activities so the physician can correlate the ECG findings with his activities. The client should continue doing his regular activities. The purpose of the Holter monitor is to record heart activity during routine activities.

Question 2 of 5.

A client is diagnosed with stage II Hodgkin's lymphoma. The nurse recognizes that the client has involvement:

A. In a single lymph node or single site

B. In more than one node or single organ on the same side of the diaphragm

C. In lymph nodes on both sides of the diaphragm

D. In disseminated organs and tissues

Explanation: Stage II Hodgkin's lymphoma involves two or more lymph nodes or a single organ on the same side of the diaphragm, per the Ann Arbor staging system.

Question 3 of 5.

When caring for a client with an anterior cervical discectomy, the nurse should give priority to assessing for post-operative bleeding. The nurse should pay particular attention to:

A. Drainage on the surgical dressing

B. Complaints of neck pain

C. Bleeding from the mouth

D. Swelling in the posterior neck

Explanation: Swelling in the posterior neck may indicate a hematoma, which can compress the airway or spinal cord, making it a priority assessment post-cervical discectomy.

Question 4 of 5.

Which of the following combinations of foods is appropriate for an eight-month-old infant?

A. Cocoa-flavored cereal, orange juice, and strained meat

B. Graham crackers, strained prunes, and pudding

C. Rice cereal, bananas, and strained carrots

D. Mashed potatoes, strained beets, and whole milk

Explanation: Rice cereal, bananas, and strained carrots are developmentally appropriate, easily digestible foods for an eight-month-old, unlike the other options, which include choking hazards or inappropriate items like whole milk.

Question 5 of 5.

A client with HELLP syndrome is admitted to the labor and delivery unit for observation. The nurse knows that the client will have elevated:

A. Serum glucose levels

B. Liver enzymes

C. Pancreatic enzymes

D. Plasma protein levels

Explanation: HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets) is characterized by elevated liver enzymes, reflecting liver dysfunction.