NCLEX-RN Exam Pack Set 1 (75
Questions and Answers () | 100%
Correct Verified Answers
1. 1. QUIZ
While examining a one-month-old infant, which of the 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
o
o
, o 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.
o 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.
o 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.
o Option B: Newborns can have irregular breathing
patterns ranging from 30 to 60 breaths per minute
with short periods of apnea (15 seconds).
o 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. QUIZ
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 patient.
List the order in which the nurse must carry out the following
actions prior to the administration of preoperative
medications.
View ANSs:
o Place the call bell within reach
o Raise the side rails on the bed
o Have the patient empty bladder
o Instruct the patient to remain in bed
o
, 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.
o Instruct the client to remain in bed. Preoperative
medications can cause drowsiness and
lightheadedness which may put the client at risk for
injury.
o Raise the side rails on the bed. Raising the side
rails on the bed helps prevent accidental falls and
injury when the client decides to get out of the bed
without assistance.
o Place the call bell within reach. Call bells should
always be within the reach of a client.
2. 3. QUIZ
A 32-year-old pregnant woman comes to the clinic for her
prenatal visit. The nurse gathers data about her obstetric history,
which includes 3-year-old twins at home and a miscarriage 10
years ago at 12 weeks gestation. How would the nurse accurately
document this information? Fill in the blanks.
o ANS: Gravida (3) para (1)
ANS: Gravida 3 para 1
Gravida is the number of confirmed pregnancies and each
pregnancy is only counted one time, even if the pregnancy was a
multiple gestation (i.e., twins, triplets). Para (parity) indicates the
total number of pregnancies that have reached viability (20
weeks) regardless of whether the infants were born alive. Thus,
for this woman, she is now pregnant, had 2 prior pregnancies,
and 1 viable birth (twins).
o 4. QUIZ
Which individual is at the greatest risk for developing
hypertension?
o A. 45-year-old African-American attorney
, o B. 60-year-old Asian-American shop owner
o C. 40-year-old Caucasian nurse
o D. 55-year-old Hispanic teacher
o
o
o
o
• 5. QUIZ
A 15-year-old female who ingested 15 tablets of maximum
strength acetaminophen 45 minutes ago is rushed to the
emergency department. Which of these orders should the nurse
do first?
o A. Gastric lavage
o B. Administer acetylcysteine (Mucomyst) orally
o C. Start an IV Dextrose 5% with 0.33% normal saline to
keep the vein open
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