NCLEX-RN
Exam Cram NCLEX RN Practice Questions Questions
Extract:
Question 1 of 5
In which of these patients would rectal temperatures be measured?
Correct Answer: B
Rationale: Rectal temperature measurement is preferred in situations where other routes are impractical or when the most accurate measure is necessary, such as in critically ill patients. The rectal route may be chosen due to its reliability in such cases. For older adults, school-age children, and patients receiving oxygen via nasal cannula, rectal temperature measurement is not typically indicated. Other routes like oral, tympanic, or axillary measurements are more commonly used in these populations due to comfort, convenience, and non-invasive nature.
Question 2 of 5
When preparing a patient on complete bed rest to eat, at what degree angle or more should you put the head of the bed up?
Correct Answer: D
Rationale: The correct answer is D: 30. When a patient is on complete bed rest, it is essential to elevate the head of the bed at a 30-degree angle or more before meals. This position helps prevent choking and aspiration of food during eating by promoting proper swallowing and digestion.
Choices A, B, and C are incorrect because they do not provide the optimal elevation needed to support safe and effective feeding for a patient on complete bed rest.
Question 3 of 5
A 4-month-old child is at the clinic for a well-baby checkup and immunizations. Which of these actions is most appropriate when the nurse is assessing an infant's vital signs?
Correct Answer: B
Rationale: The nurse auscultates an apical rate, not a radial pulse, with infants and toddlers. The pulse should be counted by listening to the heart for 1 full minute to account for normal irregularities, such as sinus dysrhythmia. Children younger than 3 years of age have such small arm vessels; consequently, hearing Korotkoff sounds with a stethoscope is difficult. The nurse should use either an electronic lood pressure device that uses oscillometry or a Doppler ultrasound device to amplify the sounds.
An infant's respiratory rate should be assessed by observing the infant's abdomen, not chest, because an infant's respirations are normally more diaphragmatic than thoracic. The nurse should auscultate an apical heart rate, not palpate a radial pulse, with infants and toddlers.
Question 4 of 5
The healthcare professional notices that a colleague is preparing to check the blood pressure of a patient who is obese by using a standard-sized blood pressure cuff. How would this likely affect the blood pressure reading?
Correct Answer: B
Rationale: Using a cuff that is too narrow for an obese patient would likely yield a falsely high blood pressure reading. This occurs because the standard cuff is too small for the arm's circumference, requiring more pressure to compress the artery. A tight cuff can lead to inaccurate and elevated blood pressure readings.
Choices A, C, and D are incorrect because using an improperly sized cuff would not yield a falsely low blood pressure, the blood pressure reading does vary with cuff size, and the technique of the person performing the assessment is not the primary factor affecting the reading in this situation.
Question 5 of 5
During change-of-shift report, the nurse learns about the following four patients. Which patient requires assessment first?
Correct Answer: C
Rationale: When prioritizing patient assessments, the nurse should address the patient with cirrhosis and ascites who has an elevated oral temperature of 102°F (38.8°
C) first. This presentation suggests a potential infection, which is critical to address promptly in a patient with liver disease. An infection in a patient with cirrhosis can quickly progress to severe complications. The other options, such as chronic pancreatitis with abdominal pain, compensated cirrhosis with anorexia, and post-laparoscopic cholecystectomy with shoulder pain, do not indicate an immediate life-threatening situation requiring urgent assessment compared to a possible infection in a patient with cirrhosis and ascites.