Fundamentals of Nursing NCLEX RN Exam Practice Q&A 4
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NCLEX RN
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NCLEX RN
Fundamentals of Nursing NCLEX RN Exam Practice Q&A| 75 Questions
1. 1. Question
All of the following can cause tachycardia except:
o A. Fever
o B. Exercise
o C. Sympathetic nervous system stimulation
o D. Parasympathetic nervous system stimulation
Incorrect
Correct Answer: D. Para...
fundamentals of nursing nclex rn exam practice qampa| 75 questions 1 1 question all of the following can cause tachycardia except o a fever o b exercise o c sympathetic nervous system s
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Fundamentals of Nursing NCLEX RN Exam Practice Q&A| 75
Questions
1. 1. Question
All of the following can cause tachycardia except:
o A. Fever
o B. Exercise
o C. Sympathetic nervous system stimulation
o D. Parasympathetic nervous system stimulation
Incorrect
Correct Answer: D. Parasympathetic nervous system
stimulation
Parasympathetic nervous system stimulation of the heart decreases
the heart rate as well as the force of contraction, rate of impulse
conduction and blood flow through the coronary vessels. Fever,
exercise, and sympathetic stimulation all increase the heart rate. The
parasympathetic nervous system (PNS) releases the hormone
acetylcholine to slow the heart rate. Such factors as stress, caffeine,
and excitement may temporarily accelerate your heart rate, while
meditating or taking slow, deep breaths may help to slow your heart
rate.
Option A: Tachypnea and tachycardia develop, and the patient
becomes dehydrated because of sweating and vapor losses from
the increased respiratory rate. Many manifestations of fever are
related to the increased metabolic rate, increased need for
oxygen, and use of body proteins as an energy source.
Option B: Often, ventricular tachycardia will occur during the
recovery period post exercise due to increased levels of
adrenaline. In a study conducted in 1991, it was found that 70%
of patients tested experienced idiopathic ventricular tachycardia
as a result of exercise. Exercising for any duration will increase
your heart rate and will remain elevated for as long as the
exercise is continued. At the beginning of exercise, your body
removes the parasympathetic stimulation, which enables the
, heart rate to gradually increase. As you exercise more
strenuously, the sympathetic system “kicks in” to accelerate your
heart rate even more.
Option C: Heart rate is controlled by the two branches of the
autonomic (involuntary) nervous system. The sympathetic
nervous system (SNS) and the parasympathetic nervous system
(PNS). The sympathetic nervous system (SNS) releases the
hormones (catecholamines – epinephrine and norepinephrine) to
accelerate the heart rate.
2. 2. Question
Palpating the midclavicular line is the correct technique for assessing:
A. Baseline vital signs
B. Systolic blood pressure
C. Respiratory rate
D. Apical pulse
Incorrect
Correct Answer: D. Apical pulse
The apical pulse (the pulse at the apex of the heart) is located on the
midclavicular line at the fourth, fifth, or sixth intercostal space.
Assessing whether the rhythm of the pulse is regular or irregular is
essential. The pulse could be regular, irregular, or irregularly irregular.
Changes in the rate of the pulse, along with changes in respiration is
called sinus arrhythmia. In sinus arrhythmia, the pulse rate becomes
faster during inspiration and slows down during expiration. Irregularly
irregular pattern is more commonly indicative of processes like atrial
flutter or atrial fibrillation.
Option A: Baseline vital signs include pulse rate, temperature,
respiratory rate, and blood pressure. Vital signs are an objective
measurement for the essential physiological functions of a living
organism. They have the name “vital” as their measurement and
assessment is the critical first step for any clinic evaluation. The
first set of clinical examinations is an evaluation of the vital signs
of the patient.
Option B: Blood pressure is typically assessed at the antecubital
fossa. The arm should be supported at the heart level.
, Unsupported arm leads to 10 mmHg to the pressure readings.
The patient’s blood pressure should get checked in each arm, and
in younger patients, it should be tested in an upper and lower
extremity to rule out the coarctation of the aorta.
Option C: Respiratory rate is assessed best by observing chest
movement with each inspiration and expiration. The respiratory
rate is the number of breaths per minute. The normal breathing
rate is about 12 to 20 beats per minute in an average adult. In
the pediatric age group, it is defined by the particular age group.
Parameters important here again include its rate, depth of
breathing, and its pattern rate of breathing is a crucial
parameter.
3. 3. Question
The absence of which pulse may not be a significant finding when a
patient is admitted to the hospital?
A. Apical
B. Radial
C. Pedal
D. Femoral
Incorrect
Correct Answer: C. Pedal
Because the pedal pulse cannot be detected in 10% to 20% of the
population, its absence is not necessarily a significant finding.
However, the presence or absence of the pedal pulse should be
documented upon admission so that changes can be identified during
the hospital stay. Absent peripheral pulses may be indicative of
peripheral vascular disease (PVD). PVD may be caused by
atherosclerosis, which can be complicated by an occluding thrombus or
embolus. This may be life-threatening and may cause the loss of a
limb.
Option A: Apical pulse rate is indicated during some
assessments, such as when conducting a cardiovascular
assessment and when a client is taking certain cardiac
medications (e.g., digoxin). Sometimes the apical pulse is
auscultated pre and post medication administration. It is also a
, best practice to assess apical pulse in infants and children up to
five years of age because radial pulses are difficult to palpate and
count in this population.
Option B: Examiners frequently evaluate the radial artery during
a routine examination of adults, due to the unobtrusive position
required to palpate it and it’s easy accessibility in various types
of clothing. Like other distal peripheral pulses (such as those in
the feet) it also may be quicker to show signs of pathology.
Palpation is at the anterior wrist just proximal to the base of the
thumb.
Option D: The femoral pulse may be the most sensitive in
assessing for septic shock and is routinely checked during
resuscitation. It is palpated distally to the inguinal ligament at a
point less than halfway from the pubis to the anterior superior
iliac spine.
4. 4. Question
Which of the following patients is at greatest risk for developing
pressure ulcers?
A. An alert, chronic arthritic patient treated with steroids and
aspirin.
B. An 88-year old incontinent patient with gastric cancer
who is confined to his bed at home.
C. An apathetic 63-year old COPD patient receiving nasal oxygen
via cannula.
D. A confused 78-year old patient with congestive heart failure
(CHF) who requires assistance to get out of bed.
Incorrect
Correct Answer: B. An 88-year old incontinent patient with
gastric cancer who is confined to his bed at home.
Pressure ulcers are most likely to develop in patients with impaired
mental status, mobility, activity level, nutrition, circulation and bladder
or bowel control. Age is also a factor. Thus, the 88-year old incontinent
patient who has impaired nutrition (from gastric cancer) and is
confined to bed is at greater risk. Pressure injuries are defined as
localized damage to the skin as well as underlying soft tissue, usually
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