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Questions 227

NCLEX-PN

NCLEX-PN Test Bank

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Extract:


Question 1 of 5

A nurse is assessing a newborn who is 1 hour old. Which of the following findings should be reported to the healthcare provider? (Select all that apply)

Correct Answer: B,C

Rationale: Nasal flaring and grunting indicate respiratory distress, requiring immediate reporting. A respiratory rate of 50 and temperature of 36.5°C are normal for a newborn.

Question 2 of 5

Order: Vancomycin HCl 1 g in 250 mL DW IVPB, infuse in 90 min. Calculate the flow rate in drops per minute. The drop factor is 20 gtt/mL.

Correct Answer: A

Rationale: 250 mL ÷ 90 min = 2.777 mL/min. 2.777 mL/min × 20 gtt/mL = 55.56 gtt/min, rounded to 56 gtt/min. Other options are incorrect.

Extract:

A patient has been receiving a cardiac glycoside, a diuretic, and a vasodilator and is on bedrest. The patient's apical pulse rate is 44.


Question 3 of 5

The nurse concludes that this pulse rate is most likely a result of the:

Correct Answer: D

Rationale: Cardiac glycosides like digoxin can cause bradycardia, especially at a pulse of 44.

Extract:


Question 4 of 5

A client with mastoiditis has a left mastoidectomy with tympanoplasty. The nurse should observe the client for signs of damage to the sixth crania nerve, which include:

Correct Answer: B

Rationale: The sixth cranial nerve (abducens) controls lateral eye movement, so damage would result in an inability to look laterally.

Extract:

You were about to give AM care, a patient requested for pain medication after returning from surgery 24 hours ago.


Question 5 of 5

What do you do first?

Correct Answer: C

Rationale: Vital signs must be assessed before administering pain medication to ensure the patient is stable and to establish a baseline.

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