NCLEX-RN
NCLEX RN Exam Questions Questions
Extract:
Question 1 of 5
A student in a cardiac unit is performing auscultation of a client’s heart. Which stethoscope placement would indicate to the nurse that the student is performing pulmonic auscultation correctly?
Correct Answer: C
Rationale: The pulmonic valve is auscultated at the second intercostal space, left of the sternum. Apex/sternum (
A) is nonspecific, fifth intercostal space (
B) is for the mitral valve, and manubrium (
D) is not a standard site.
Question 2 of 5
A terrorist attack has left hundreds of patients with injuries determined to be in the immediate category as defined by NATO. The color to designate this group is:
Correct Answer: C
Rationale: In NATO triage the immediate category (requiring urgent intervention to survive) is designated by red. Black indicates deceased or expectant yellow is delayed and green is minimal.
Question 3 of 5
The nurse is preparing to administer a dose of lorazepam (Ativan) for anxiety. Which assessment is most important before administration?
Correct Answer: B
Rationale: Lorazepam, a benzodiazepine, can cause respiratory depression, so assessing respiratory rate is critical before administration. Other vital signs are monitored but are less specific.
Question 4 of 5
The primary reason for sending a burn client home with a pressure garment, such as a Jobst garment, is that the garment:
Correct Answer: A
Rationale: Pressure garments apply uniform pressure to prevent or reduce hypertrophic scarring, which is critical during the recovery phase of burn care.
Question 5 of 5
A 4-year-old child is being discharged from the hospital after being treated for severe croup. Which one of the following instructions should the nurse give to the child's mother for the home treatment of croup?
Correct Answer: A
Rationale: Initial home treatment of croup includes placing the child in an environment of high humidity to liquefy and mobilize secretions. Antihistamines should be avoided because they can cause thickening of secretions. Drooling is a characteristic sign of airway obstruction and the child should be taken directly to the emergency room. Crying increases respiratory distress and hypoxia in the child with croup. The nurse should promote methods that will calm the child.