1. 1. Question
Category: Health Promotion and Maintenance
A pediatric nurse is performing a routine assessment of a one-month-old infant
during a well-baby visit at the primary care clinic. The infant’s mother reports no
concerns and states that the baby has been feeding well and has had regu...
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NCLEX RN Exam May 2023
Actual Questions & Answers
Bank with Rationales
100% Verified Q&A
David.jamin19@gmail.com
,NCLEX RN Exam May 2023
900 Actual Questions & Answers with
Rationales
,1. 1. Question
Category: Health Promotion and Maintenance
A pediatric nurse is performing a routine assessment of a one-month-old infant
during a well-baby visit at the primary care clinic. The infant’s mother reports no
concerns and states that the baby has been feeding well and has had regular
bowel movements. Upon assessment, which of the following findings warrants
further investigation by the nurse? Select all that apply.
o A. Abdominal respirations
o B. Irregular breathing rate
o C. Inspiratory grunt
o D. Increased heart rate with crying
o E. Nasal flaring
o F. Cyanosis
o G. Asymmetric chest movement
Correct Answers: C, E, F, & G
Option C. Grunting occurs when an infant attempts to maintain an
adequate functional residual capacity in the face of poorly compliant lungs
by partial glottic closure. As the infant prolongs the expiratory phase
against this partially closed glottis, there is a prolonged and increased
residual volume that maintains the airway opening and also an audible
expiratory sound.
Option E: Nasal flaring occurs when the nostrils widen while breathing and
is a sign of troubled breathing or respiratory distress.
Option F: Cyanosis refers to the bluish discoloration of the skin and
indicates a decrease in oxygen attached to the red blood cells in the
bloodstream.
Option G: Asymmetric chest movement occurs when the abnormal side of
the lungs expands less and lags behind the normal side. This indicates
respiratory distress.
, Option A: Abdominal respiration is normal among infants and young
children. Since their intercostal muscles are not yet fully developed, they
use their abdominal muscles much more to pull the diaphragm down for
breathing.
Option B: Newborns can have irregular breathing patterns ranging from
30 to 60 breaths per minute with short periods of apnea (15 seconds).
Option D: An increase in heart rate is normal for an infant during activity
(including crying). Fluctuations in heart rate follow the changes in the
newborn’s behavioral state – crying, movement, or wakefulness
corresponds to an increase in heart rate.
2. 2. Question
Category: Pharmacological and Parenteral Therapies
A nurse is to administer meperidine hydrochloride (Demerol) 100 mg, atropine
sulfate (Atropisol) 0.4 mg, and promethazine hydrochloride (Phenergan) 50 mg
IM to a preoperative client. List the order in which the nurse must carry out
the following actions prior to the administration of preoperative
medications.
View Answers:
Place the call bell within reach
Have the client empty bladder
Instruct the client to remain in bed
Raise the side rails on the bed
Correct order is shown above.
4. Have the client empty the bladder. The first step in the process is to have
the client void prior to administering the pre-operative medication. If the
client does not have a catheter, it is important to empty the bladder before
receiving preoperative medications to prevent bladder injury (especially in
pelvic surgeries). Else, a straight catheter or an indwelling catheter may be
ordered to ensure the bladder is empty.
5. Instruct the client to remain in bed. Preoperative medications can cause
drowsiness and lightheadedness which may put the client at risk for injury.
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