Exam Cram NCLEX RN Practice Questions - Nurselytic

Correct Answer: C

Rationale: For accurate measurements, specific techniques are required for different parameters in infants. Measuring the chest circumference involves encircling the chest at the nipple line. Length should be measured on a horizontal measuring board. Weight should be measured using a platform-type balance scale. Head circumference measurement entails ensuring the tape is aligned at the eyebrows and prominent frontal and occipital bones for the widest span.
Therefore, the correct technique for measuring the chest circumference is at the nipple line with a tape measure. The other options are incorrect because length should be measured on a horizontal board, weight should be measured on a balance scale, and head circumference should be measured around the head, not over the nose and cheekbones.

Correct Answer: A

Rationale: When assessing vital signs in a 6-month-old infant, the correct order is to measure respirations first, followed by pulse and temperature. This sequence is important to avoid potential alterations in respiratory and pulse rates caused by factors like crying or discomfort. Measuring the temperature first, especially rectally, may lead to an increase in respiratory and pulse rates, which can skew the results. It is crucial to follow this specific order to obtain accurate baseline values.
Therefore, option A is the correct choice. Option B is incorrect as the frequency of measuring vital signs in infants differs based on individual needs rather than being consistently more frequent than in adults. Option C is not directly related to the correct sequence for measuring vital signs in infants. Option D is incorrect because the physical examination typically follows the assessment of vital signs in clinical practice.

Correct Answer: B

Rationale: The correct answer is to delegate the task of setting up oxygen and suction equipment to the LPN/LVN. This task falls within their scope of practice and can be safely performed by them. Completing the admission assessment (
Choice
A) typically requires a higher level of assessment and critical thinking, making it more appropriate for a registered nurse. Placing a padded tongue blade at the bedside (
Choice
C) involves potential airway management, which is a more complex task and should be done by a higher-level provider. Padding the side rails before the patient arrives (
Choice
D) is a task related to patient safety and should be done by the healthcare team as a whole, not solely delegated to an LPN/LVN.

Correct Answer: B

Rationale: Starting prophylactic AZT treatment is the most critical intervention in this scenario. Azidothymidine (AZT) is an antiretroviral medication used to prevent and treat HIV/AIDS by reducing the replication of the virus. Post-exposure prophylaxis (PEP) for HIV involves taking medication to suppress the virus and prevent infection after exposure. PEP should be initiated within 72 hours of potential HIV exposure to be effective. Seeking treatment quickly is crucial to enhance its effectiveness. Seeing a social worker (
Choice
A) may be helpful for emotional support but is not the immediate priority. Pentamidine treatment (
Choice
C) is not indicated for post-exposure prophylaxis for HIV. Seeking counseling (
Choice
D) is important for the nursing student's emotional well-being but does not address the urgent need for post-exposure prophylaxis to prevent HIV transmission.

Correct Answer: A

Rationale:
To accurately assess a rectal temperature in an adult, a nurse should use a lubricated rectal thermometer with a short, blunt tip. The thermometer is inserted only 2 to 3 cm (1 inch) into the rectum and left in place for 2 minutes.
Choice B is incorrect as inserting the thermometer 2 to 3 inches would be too deep and inaccurate.
Choice C is incorrect as leaving the thermometer in place for up to 8 minutes is unnecessary and can cause discomfort.
Choice D is incorrect as smoking a cigarette does not impact rectal temperatures.