NCLEX-RN
Exam Cram NCLEX RN Practice Questions Questions
Extract:
Question 1 of 5
When measuring the vital signs of a 6-month-old infant, which action by the nurse is correct?
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.
Question 2 of 5
Your patient ate an 8-ounce cup of Italian ice. How much will you record on the patient's Intake and Output form in terms of this patient's fluid intake?
Correct Answer: A
Rationale: The correct answer is 240 cc. Italian ice is considered a fluid, so you would record the intake of 240 cc.
Choice B (120 cc) and
Choice C (8 cc) are incorrect as they do not reflect the correct amount of fluid intake from an 8-ounce cup of Italian ice.
Choice D (0 cc) is incorrect because Italian ice does count as a fluid intake and should be recorded as such.
Question 3 of 5
When evaluating the temperature of older adults, what aspect should the healthcare provider remember about an older adult's body temperature?
Correct Answer: A
Rationale: When evaluating the temperature of older adults, it is important to note that their body temperature is usually lower than that of younger adults, with a mean temperature of 36.2°C.
Choice B is incorrect because an older adult's body temperature is not approximately the same as that of a young child.
Choice C is incorrect because body temperature is a physiological parameter and does not vary based on the type of thermometer used.
Choice D is incorrect because while older adults may have less effective heat control mechanisms, their body temperature is typically lower, not widely fluctuating.
Question 4 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 5 of 5
Which of these actions illustrates the correct technique for a nurse when assessing oral temperature with a glass thermometer?
Correct Answer: B
Rationale: The correct technique for assessing oral temperature with a glass thermometer involves leaving the thermometer in place for 3 to 4 minutes if the patient is afebrile and up to 8 minutes if the patient is febrile. Waiting 30 minutes if the patient has ingested hot or iced liquids is incorrect; instead, the nurse should wait 15 minutes in such cases. Shaking the glass thermometer down to 35.5°C, not 37.5°C, is the correct procedure before taking the patient's temperature. Placing the thermometer at the base of the tongue, not the front, and asking the patient to close their lips is the proper way to position the thermometer.
Therefore, the correct answer is to leave the thermometer in place for 3 to 4 minutes if the patient is afebrile and up to 8 minutes if the patient is febrile.