NCLEX-RN
Exam Cram NCLEX RN Practice Questions Questions
Extract:
Question 1 of 5
A parent calls the pediatric clinic and is frantic about the bottle of cleaning fluid her child drank for 20 minutes. Which of the following is the most important instruction the nurse can give the parent?
Correct Answer: C
Rationale: In situations where a child has ingested a potentially harmful substance, contacting the Poison Control Center quickly is crucial. The Poison Control Center can provide specific guidance tailored to the child's situation, which can include whether immediate medical attention is necessary or if any actions need to be taken at home. Option A, 'This too shall pass,' is not appropriate as it dismisses the seriousness of the situation. Option B, 'Take the child immediately to the ER,' may not always be the best course of action without guidance from experts. Option D, 'Give the child syrup of ipecac,' is outdated advice and not recommended as a first response to poisoning incidents.
Question 2 of 5
How many cc are there in 25 ounces?
Correct Answer: C
Rationale:
To convert ounces to cc, we know that there are 30 cc in 1 ounce.
Therefore, to find out how many cc are in 25 ounces, we multiply 30 cc/ounce by 25 ounces which equals 750 cc. This makes choice C, 750, the correct answer.
Choices A, B, and D are incorrect as they do not correctly convert ounces to cc.
Question 3 of 5
The patient with migraine headaches has a seizure. After the seizure, which action can you delegate to the nursing assistant?
Correct Answer: C
Rationale: After a patient with migraine headaches has a seizure, it is important to assess their vital signs to monitor their condition. This task can be safely delegated to a nursing assistant as it falls within their scope of practice. Documenting the seizure and performing neurologic checks require a higher level of training and should be done by a nurse or healthcare provider. Restraint should never be used as a first-line intervention after a seizure unless there is an immediate threat to the patient's safety, and it should be done following proper protocols and with appropriate training.
Question 4 of 5
A patient is seen in the clinic for reports of "fainting episodes that started last week."? How would the nurse proceed with the examination?
Correct Answer: C
Rationale: When a patient reports fainting episodes, it is crucial to assess for orthostatic hypotension. If the nurse suspects volume depletion, the patient has hypertension, is on antihypertensive medications, or has a history of fainting or syncope, blood pressure readings should be taken in three positions: lying, sitting, and standing. This assessment helps detect orthostatic hypotension, which can provide valuable information about the patient's condition. Taking blood pressure readings in multiple positions allows for a comprehensive evaluation of possible postural changes in blood pressure.
Choices A, B, and D are incorrect because they do not cover the necessary positions to assess for orthostatic hypotension effectively.
Question 5 of 5
A 1-month-old infant has a head measurement of 34 cm and a chest circumference of 32 cm. Based on the interpretation of these findings, what action would the nurse take?
Correct Answer: B
Rationale: In infants, a normal head measurement is approximately 32 to 38 cm, and it is usually around 2 cm larger than the chest circumference. These measurements vary with age; between 6 months and 2 years, both measurements are approximately the same, and after age 2 years, the chest circumference becomes greater than the head circumference. Given that the 1-month-old infant's head measurement is within the typical range and slightly larger than the chest circumference, the nurse should consider these findings normal. There is no indication to refer the infant for further evaluation or to have the parent return for re-evaluation in 2 weeks, as these measurements fall within the expected parameters for a 1-month-old infant.