Exam Cram NCLEX RN Practice Questions - Nurselytic

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: D

Rationale: The disappearance of phase V Korotkoff sounds can be used for the diastolic reading in children, as well as in adults. Blood pressure guidelines for children are based on more than just age, but also sex and height. Phase I Korotkoff, not Phase II, is the best indicator of systolic blood pressure. The true statement regarding the measurement of blood pressure in children is that the disappearance of phase V Korotkoff sounds can be used for the diastolic reading in children, as well as in adults.

Correct Answer: C

Rationale: When blood pressure measured in the arm is significantly elevated, especially in adolescents and young adults, it is crucial to compare it with thigh pressure to assess for coarctation of the aorta. The popliteal artery, not the femoral artery, should be auscultated for the thigh pressure reading as the femoral artery is closer to the placement of the blood pressure cuff. Generally, thigh pressure is higher than arm pressure; however, if there is coarctation of the artery, arm pressures can be higher than thigh pressures. The preferred position for measuring thigh pressure is the prone position, not supine, with the knee slightly bent to facilitate accurate readings.

Correct Answer: C

Rationale: The systolic pressure is the maximum pressure felt on the artery during left ventricular contraction, or systole. The diastolic pressure is the elastic recoil, or resting, pressure that the blood constantly exerts in between each contraction. The nurse should answer the patient's question in terms they can understand and not just say it is normal and there is nothing to worry about. The diastolic pressure is the pressure in the vessels when the heart is at rest, not the stroke volume. Both the systolic and diastolic blood pressure are important.
Choice A is incorrect as providing a vague reassurance does not address the patient's query.
Choice B is incorrect as it inaccurately describes the diastolic pressure as reflecting stroke volume, which is incorrect.
Choice D is incorrect as it oversimplifies the explanation, focusing solely on the top number without providing a complete understanding of blood pressure.

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.