NCLEX-RN
Exam Cram NCLEX RN Practice Questions Questions
Extract:
Question 1 of 5
The nurse is assessing the vital signs of a 3-year-old patient who appears to have an irregular respiratory pattern. How would the nurse assess this child's respirations?
Correct Answer: A
Rationale:
To accurately assess a child's respiratory pattern, the nurse should count respirations for a full minute. This duration provides a comprehensive view of the child's breathing pattern, ensuring abnormalities are not missed. Counting for only 30 seconds may not capture irregularities effectively. Checking respirations for 5 minutes is excessive and unnecessary for a routine assessment. Counting for 15 seconds and multiplying by 4 is not as precise as a full-minute count. Pulse and respirations should not be checked simultaneously; instead, the nurse should count respirations unobtrusively while appearing to take the child's pulse.
Therefore, the correct approach is to count the child's respirations for 1 full minute to obtain an accurate assessment.
Question 2 of 5
When considering the concepts related to blood pressure, which statement best describes the concept of mean arterial pressure (MAP)?
Correct Answer: C
Rationale: Mean Arterial Pressure (MAP) is the pressure that forces blood into the tissues, averaged over the cardiac cycle. It is not the pressure of the arterial pulse (
Choice
A), nor does it directly reflect the stroke volume of the heart (
Choice
B). While MAP involves systolic and diastolic pressures, it is not simply an average of these two values as diastole lasts longer. Instead, MAP is closer to diastolic pressure plus one third of the pulse pressure. The best description of MAP is that it represents the pressure forcing blood into the tissues, averaged over the cardiac cycle.
Question 3 of 5
Which of these specific measurements is the best index of a child's general health?
Correct Answer: B
Rationale: Height and weight are the most accurate measurements to assess a child's general health. These measurements reflect the physical growth and development of the child, indicating overall health status.
Choices C and D, head circumference and chest circumference, are important measurements for specific assessments but do not provide as comprehensive an overview of general health as height and weight. Body mass index (BMI) is a calculation based on height and weight, making height and weight more direct and primary indicators of a child's health compared to BMI.
Question 4 of 5
During the evaluation of the quality of home care for a client with Alzheimer's disease, the priority for the nurse is to reinforce which statement by a family member?
Correct Answer: C
Rationale: The correct answer is, '"We have safety bars installed in the bathroom and have 24-hour alarms on the doors."?' Ensuring the safety of a client with Alzheimer's disease is crucial in home care. Installing safety features like bars in the bathroom and alarms on doors help prevent accidents and injuries. This contributes to creating a safe environment that promotes independence and autonomy for the client.
Choices A, B, and D are incorrect because while they are important aspects of care, ensuring safety in the home environment takes precedence in caring for a client with Alzheimer's disease.
Question 5 of 5
A student is late for an appointment and has rushed across campus to the health clinic. How should the nurse proceed?
Correct Answer: A
Rationale:
To ensure an accurate blood pressure reading, it is important for the student to be in a relaxed state. Allowing at least a 5-minute rest period helps reduce anxiety and provides a valid blood pressure measurement. Checking the blood pressure in both arms is unnecessary unless there is a specific reason to suspect an issue, and recent exercise should not significantly impact the readings. Monitoring vital signs immediately upon arrival may not yield accurate results due to the rush and anxiety of the student. Checking blood pressure in the supine position is not necessary in this scenario and does not provide a more accurate reading.