NCLEX RN Simulated Exam Test Bank

Extract:

Question 1 of 5

You have been assigned to take an apical pulse for one of the patients on the nursing unit. How will you do this?

Correct Answer: B

Rationale:
To take an apical pulse accurately, you should place the stethoscope over the heart and count the number of beats per minute. This method provides a precise assessment of the heart rate. While listening for irregular beats is essential for assessing the heart's rhythm, the primary objective of taking an apical pulse is to determine the heart rate.

Choices C and D are incorrect because the apical pulse is not taken at the wrist; instead, it is obtained by auscultating at the apex of the heart, usually at the point where the fifth intercostal space meets the midclavicular line.

Question 2 of 5

A patient is asked to abduct her arms. Which of the following accurately describes her arm movement?

A. She moves her arms away from her trunk B. She moves her arms toward her trunk C. She rotates her arms at the wrists while holding them away from her body D. She crosses her arms over her abdomen

Correct Answer: A

Rationale: Abduction refers to moving a body part away from the midline of the body. In this case, when the patient abducts her arms, she is moving them away from her trunk.
Choice A is correct.

Choices B, C, and D are incorrect.
Choice B describes adduction, which is the movement of a body part toward the midline.
Choice C describes wrist rotation, not arm abduction.
Choice D describes crossing the arms over the abdomen, which is not the movement associated with abduction.

Question 3 of 5

The nurse is developing a plan of care for an infant after surgical intervention for imperforate anus. The nurse should include in the plan that which position is the most appropriate one for the infant in the postoperative period?

A. Prone position B. Supine with no head elevation C. Side-lying with the legs extended D. Supine with the head elevated 45 degrees

Correct Answer: A

Rationale: The most appropriate position for an infant after surgical intervention for imperforate anus is the prone position. Placing the infant in a prone position helps keep the hips elevated, reducing edema and pressure on the surgical site. This position promotes optimal healing and comfort for the infant. Option B, supine with no head elevation, does not provide the necessary elevation to reduce pressure on the surgical site. Option C, side-lying with the legs extended, does not offer the same benefits as the prone position in terms of reducing pressure on the surgical site. Option D, supine with the head elevated 45 degrees, does not specifically address the need for hip elevation to prevent pressure on the surgical site.
Therefore, the correct choice is the prone position for this postoperative care scenario.

Question 4 of 5

Which brain structure serves as the heat-regulating center?

A. Hypothalamus B. Pituitary Gland C. Pons D. Medulla Oblongata

Correct Answer: A

Rationale: The correct answer is the Hypothalamus. The hypothalamus is responsible for regulating body temperature, ensuring it stays within a narrow range. Moreover, the hypothalamus controls various essential bodily functions, such as hunger, thirst, and circadian rhythms.

Choices B, C, and D are incorrect because the Pituitary Gland primarily produces and releases hormones, the Pons is involved in functions like sleep, respiration, and bladder control, and the Medulla Oblongata controls vital functions like breathing and heart rate, but not body temperature regulation.

Question 5 of 5

A registered nurse who usually works in a spinal rehabilitation unit is floated to the emergency department. Which of these clients should the charge nurse assign to this RN?

A. A middle-aged client who says, "I took too many diet pills"? and "my heart feels like it is racing out of my chest."? B. A young adult who says, "I hear songs from heaven. I need money for beer. I quit drinking two (2) days ago for my family. Why are my arms and legs jerking?"? C. An adolescent who has been on pain medications for terminal cancer with an initial assessment finding of pinpoint pupils and a relaxed respiratory rate of 11. D. An elderly client who reports having taken a "large crack hit"? 10 minutes prior to walking into the emergency room.

Correct Answer: C

Rationale: When assigning a floated nurse from another unit to a client in the emergency department, the goal is to choose a patient with minimal anticipated immediate complications. In this scenario, the adolescent with terminal cancer who has been on pain medications and presents with pinpoint pupils and a relaxed respiratory rate of 11 is the most stable option. These assessment findings indicate opioid toxicity, which, while serious, has the least risk of immediate complications compared to the other clients.
Choice A involves a middle-aged client experiencing symptoms of possible cardiac issues due to diet pill overdose, which requires urgent intervention.
Choice B presents a young adult with concerning symptoms of potential psychosis or substance withdrawal, requiring immediate attention.
Choice D involves an elderly client who recently used crack, posing a high-risk situation that requires prompt evaluation and intervention.
Therefore, the correct choice is the adolescent with opioid toxicity, as this client has the least immediate risk of complications among the options provided.

NCLEX RN Simulated Exam Test Bank - Nurselytic

Nurselytic

NCLEX-RN

NCLEX-RN