NCLEX-RN
Exam Cram NCLEX RN Practice Questions Questions
Extract:
Question 1 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 2 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.
Question 3 of 5
When counting an infant's respirations, which technique is correct?
Correct Answer: B
Rationale: The correct technique for counting an infant's respirations is to observe the movement of the abdomen. Infants typically have more diaphragmatic breathing than thoracic, so watching the abdomen provides a more accurate count. Placing a hand on the chest or listening with a stethoscope can alter the infant's breathing pattern and provide inaccurate results.
Therefore, options A, C, and D are incorrect methods for counting an infant's respirations. By observing the movement of the abdomen, healthcare providers can accurately assess an infant's respiratory rate without influencing their breathing pattern.
Question 4 of 5
When assessing the pulse of a 6-year-old patient, the nurse notices that the heart rate varies with the respiratory cycle, speeding up at the peak of inspiration and slowing to normal with expiration. What action would the nurse take next?
Correct Answer: B
Rationale: The correct action for the nurse to take next is to record this finding as normal. Sinus dysrhythmia, characterized by heart rate variation with the respiratory cycle, is commonly found in children and young adults. The heart rate speeds up at the peak of inspiration and slows to normal with expiration. This phenomenon is a normal variant and does not require any intervention. There is no need to notify the physician as this finding is within the expected range for this age group. Checking the child's blood pressure for variations with respiration or documenting the child as having bradycardia would not be appropriate in this case, as sinus dysrhythmia is a normal physiological response.
Question 5 of 5
Which of the following puts the layers of skin in the correct order from right to left?
Correct Answer: C
Rationale: The correct order of the layers of skin from outermost to innermost is the epidermis, dermis, and then the hypodermis. The epidermis is the outermost layer of the skin, followed by the dermis, which is the middle layer containing connective tissue, hair follicles, and sweat glands. The hypodermis, also known as the subcutaneous tissue, lies beneath the dermis and consists of fat and connective tissue.
Choice A is incorrect as it lists the layers in the reverse order.
Choice B is incorrect as it reverses the order of the layers.
Choice D is incorrect as there is a correct answer among the choices.