NCLEX-RN
NCLEX RN Free Practice Questions Questions
Extract:
Question 1 of 5
A 4-week-old infant is admitted to the emergency room in respiratory distress. Which of the following statements indicates the nurse's knowledge of the anatomy of the respiratory system in pediatric clients?
Correct Answer: A
Rationale: The airway in children is much smaller than it is in adults. The diameter of the trachea in the newborn is 4 mm and that of the adult is 20 mm. A small change in the diameter of the airway can make a major difference in the pediatric client. The tongue is proportionally larger in children and fills most of the oral cavity, thereby decreasing air space. The entire pediatric airway is elastic. Elasticity diminishes with age, however. The distances between respiratory structures are shorter than that of adults, and therefore organisms are able to move more rapidly down the throat, leading to more extensive respiratory involvement.
Question 2 of 5
A registered nurse is trying to determine the appropriate care that she should provide for her obstetrical clients. Which of the following documents is considered the legal standard of practice?
Correct Answer: A
Rationale: The state nursing practice act determines the standard of care for the professional nurse. AWHONN Standards are published as recommendations and guidelines for maternal-newborn nursing. American Nurses' Association Standards are published as recommendations and guidelines for maternal-child health nursing. The International Council of Nurses' Code emphasizes the nurse's obligations to the client rather than to the physician. It is published as recommendations and guidelines by the international organization for professional nursing.
Question 3 of 5
The nurse is preparing to administer an injection to a six-month-old when she notices a white dot in the infant's right pupil. The nurse should:
Correct Answer: A
Rationale: A white dot in the pupil (leukocoria) may indicate retinoblastoma or other serious conditions, requiring immediate reporting to the physician for evaluation.
Question 4 of 5
A 19-year-old client fell off a ladder approximately 3 ft to the ground. He did not lose consciousness but was taken to the emergency department by a friend to have a scalp laceration sutured. The nurse instructs the client to:
Correct Answer: C
Rationale: Confusion, nausea, or vomiting may indicate increasing intracranial pressure from a possible head injury, requiring immediate evaluation.
Question 5 of 5
A client is admitted to the labor room. She is dilated 4 cm. She is placed on electric fetal monitoring. Which of the following observations necessitates notifying the physician?
Correct Answer: A
Rationale: These are tetanic in nature and can cause rupture of the uterus. The FHR decreases during contractions owing to vasoconstriction and should recover after the contraction. Beat-to-beat variability is a normal finding and demonstrates fetal well-being. The FHR may decrease at the beginning of a contraction owing to head compression.