NCLEX-RN
Exam Cram NCLEX RN Practice Questions
1. A 70-year-old man has a blood pressure of 150/90 mm Hg in a lying position, 130/80 mm Hg in a sitting position, and 100/60 mm Hg in a standing position. How should the nurse evaluate these findings?
- A. These readings are a normal response and attributable to changes in the patient's position.
- B. The change in blood pressure readings is called orthostatic hypotension.
- C. The blood pressure reading in the lying position is within normal limits.
- D. The change in blood pressure readings is considered within normal limits for the patient's age.
Correct answer: B
Rationale: The correct answer is, 'The change in blood pressure readings is called orthostatic hypotension.' Orthostatic hypotension is defined as a drop in systolic pressure of �20 mm Hg or �10 mm Hg drop in diastolic pressure that occurs with a quick change to a standing position. This condition is common in individuals on prolonged bed rest, older adults, those with hypovolemia, or taking specific medications. The blood pressure readings provided in the question (150/90 mm Hg lying, 130/80 mm Hg sitting, and 100/60 mm Hg standing) demonstrate a significant change in blood pressure with position changes, which is indicative of orthostatic hypotension. Choices A, C, and D are incorrect because the readings do not indicate a normal response or blood pressure within normal limits for the patient's age; rather, they suggest the presence of orthostatic hypotension.
2. The Atlas and the Axis are:
- A. found in the vertebrae.
- B. described as being cervical.
- C. the first two bones that form the column for the spine on the superior aspect.
- D. All of the above.
Correct answer: D
Rationale: The Atlas and the Axis are the first two cervical vertebrae, designated as C1 and C2. The Atlas (C1) supports the skull, while the Axis (C2) allows for rotation of the skull. Therefore, all the statements in choices A, B, and C are correct, making 'All of the above' the correct answer. Choice A is correct as the Atlas and Axis are indeed found in the vertebrae. Choice B is correct as they are the first two cervical vertebrae. Choice C is correct as these bones form the superior aspect of the spine.
3. A parent calls the pediatric clinic and is frantic about the bottle of cleaning fluid her child drank for 20 minutes. Which of the following is the most important instruction the nurse can give the parent?
- A. This too shall pass.
- B. Take the child immediately to the ER
- C. Contact the Poison Control Center quickly
- D. Give the child syrup of ipecac
Correct answer: C
Rationale: In situations where a child has ingested a potentially harmful substance, contacting the Poison Control Center quickly is crucial. The Poison Control Center can provide specific guidance tailored to the child's situation, which can include whether immediate medical attention is necessary or if any actions need to be taken at home. Option A, 'This too shall pass,' is not appropriate as it dismisses the seriousness of the situation. Option B, 'Take the child immediately to the ER,' may not always be the best course of action without guidance from experts. Option D, 'Give the child syrup of ipecac,' is outdated advice and not recommended as a first response to poisoning incidents.
4. A client has fallen asleep in his bed in the hospital. His heart rate is 65 bpm, his muscles are relaxed, and he is difficult to arouse. Which stage of the sleep cycle is this client experiencing?
- A. Stage 1
- B. Stage 2
- C. Stage 3
- D. Stage 4
Correct answer: C
Rationale: The client in this scenario is experiencing stage 3 of the sleep cycle. In stage 3, the individual has moved into deeper stages of sleep, making it difficult to arouse. Characteristics of stage 3 include relaxed muscles, a decrease in vital signs, and being very still. Stage 3 is a phase of non-REM sleep where the client progresses towards REM sleep and vivid dreams. Choices A, B, and D are incorrect. Stage 1 is characterized by light sleep, stage 2 is a slightly deeper sleep with sleep spindles and K-complexes, and stage 4 is the deepest stage of sleep with the slowest brain waves.
5. A 2-year-old child has been brought to the clinic for a well-child checkup. What is the best way for the nurse to begin the assessment?
- A. Ask the parent to place the child on the examining table.
- B. Have the parent remove all of the child's clothing before the examination.
- C. Allow the child to keep a security object such as a toy or blanket during the examination.
- D. Initially focus the interactions on the child, essentially ignoring the parent until the child's trust has been obtained.
Correct answer: C
Rationale: The best place to examine the toddler is on the parent's lap. Toddlers understand symbols; therefore, a security object is helpful. Initially, the focus is more on the parent, which allows the child to adjust gradually and to become familiar with you. A 2-year-old child does not like to take off his or her clothes. Therefore, ask the parent to undress one body part at a time.
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