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Questions 227

NCLEX-PN

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Extract:

After 1 minute after birth, the nurse notes that an infant is crying, has a heart rate of 140, has acrocyanosis, resists the suction catheter, and keeps arms extended.


Question 1 of 5

The nurse should assign this infant an Apgar score of:

Correct Answer: C

Rationale: Crying (2), HR 140 (2), acrocyanosis (1), resists suction (2), extended arms (1) yield an Apgar of 8.

Extract:

Which of the following individuals is at greatest risk for experiencing cerebral vascular accident?


Question 2 of 5

A 50-year-old African-American male with history of hypertension.

Correct Answer: A

Rationale: This patient has multiple risk factors for CVA: African-American race, male gender, age, and hypertension.

Extract:


Question 3 of 5

The CVP reading of a client with partial thickness burns is 6 mm H2O. The nurse recognizes that the client:

Correct Answer: B

Rationale: A central venous pressure (CVP) reading of 6 mm H2O is within the normal range (2-8 mm H2O), indicating adequate fluid status. Answer A is incorrect because the client does not need additional fluids. Answer C is incorrect because a CVP of 6 does not suggest congestive failure. Answer D is incorrect because a diuretic is not indicated with a normal CVP.

Question 4 of 5

The nurse is caring for clients on the neurology unit. What would be the MOST appropriate action for the nurse to take after noting that a client suddenly developed a fixed and dilated pupil?

Correct Answer: D

Rationale: A fixed and dilated pupil is a neurological emergency, often indicating increased intracranial pressure (ICP) or brain herniation. Immediate physician notification is critical for timely intervention. Reassessing in five minutes delays care, checking visual acuity is irrelevant, and lowering the bed could worsen ICP.

Extract:

A nurse picks up an order for an asthmatic child. The order reads: Propranolol (Inderal) 80 mg. PO QD.


Question 5 of 5

The nurse reads this order as

Correct Answer: B

Rationale: Propranolol, a beta-blocker, is contraindicated in asthma due to risk of bronchoconstriction.

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