the nurse would make which of the following inferences after performing the appropriate client assessment the nurse would make which of the following inferences after performing the appropriate client assessment
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Nursing Elites

NCLEX NCLEX-RN

NCLEX RN Predictor Exam

1. After performing the appropriate client assessment, which of the following inferences would the nurse make?

Correct answer: Client is hypotensive

Rationale: An inference is the nurse's judgment or interpretation of cues gathered during an assessment. In this scenario, identifying a client as hypotensive would be an inference based on blood pressure readings that indicate lower than normal values. Respiratory rate and oxygen saturation levels (choices B and C) are important cues that provide additional data but do not directly point to a specific conclusion like hypotension. The client expressing anxiety about blood work (choice D) is relevant information but relates more to their emotional state rather than a physiological assessment finding.

2. When caring for a single client during one shift, it is appropriate for the nurse to reuse only which of the following personal protective equipment?

Correct answer: Goggles

Rationale: Goggles may be reused unless they are overly contaminated by material that has splashed in the nurse’s face and cannot be effectively rinsed off. Gowns are at high risk for contamination and should be used only once and then discarded or washed. Surgical masks and gloves should never be washed or reused. Goggles provide eye protection from splashes and should be cleaned and disinfected after each use to ensure proper protection.

3. A client with right-sided heart failure is being assessed by a nurse. Which of the following symptoms would the nurse most likely observe in this client?

Correct answer: B: Coughing and 3+ pitting edema

Rationale: In right-sided heart failure (cor pulmonale), the right side of the heart struggles to pump blood to the lungs. This leads to symptoms related to fluid buildup in the body, such as coughing due to respiratory distress and 3+ pitting edema, commonly seen in the feet and ankles. Weight loss and vomiting (Choice A) are not typical symptoms of right-sided heart failure. Muscle cramps and hyperreflexia (Choice C) are more indicative of electrolyte imbalances or neurological issues. Lethargy and paroxysmal nocturnal dyspnea (Choice D) are commonly associated with left-sided heart failure, not right-sided heart failure.

4. The OR nursing staff are preparing a client for a surgical procedure. The anesthesiologist has given the client medications, and the client has entered the induction stage of anesthesia. The nursing staff can expect which of the following symptoms and activities from the client during this time?

Correct answer: D: Euphoria, drowsiness, dizziness

Rationale: During the induction stage of anesthesia, the client may exhibit symptoms like euphoria, drowsiness, or dizziness. This stage occurs after the administration of medications by the anesthesiologist and ends when the client loses consciousness. Choice A is incorrect as irregular breathing patterns are not typically associated with the induction stage. Choice B is incorrect as minimal heartbeat and dilated pupils are not commonly observed during this stage. Choice C is incorrect as relaxed muscles, regular breathing, and constricted pupils are not indicative of the induction stage of anesthesia.

5. Your elderly patient has a temperature of 98.5 degrees. Is there anything else that a nurse should do, in addition to documenting this temperature?

Correct answer: No, this temperature is within normal limits.

Rationale: No, there is nothing else that a nurse should do. A temperature of 98.5 degrees for an elderly patient falls within normal limits. Other choices are incorrect because the temperature is not hyperthermic (abnormally high) or hypothermic (abnormally low), making choices B, C, and D inaccurate responses in this scenario.

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