NCLEX-RN
NCLEX RN Actual Exam Test Bank
1. How does the procedure for taking a pulse rate on an infant differ from an adult?
- A. Pulse rates are taken on infants using a different method.
- B. The apical pulse method is used on infants.
- C. Pulse rates on infants are taken with a sphygmomanometer.
- D. Pulse rates on infants are taken apically in the third intercostal space.
Correct answer: B
Rationale: The correct answer is B: The apical pulse method is used on infants. This method involves placing a stethoscope in the fifth intercostal space, mid-clavicular line, and counting the beats for a full minute. It is a preferred method for infants due to their small size and the difficulty in palpating peripheral pulses accurately. Choices A, C, and D are incorrect. Choice A is incorrect as pulse rates are indeed taken on infants, albeit using a different method. Choice C is incorrect as a sphygmomanometer is typically used for measuring blood pressure, not pulse rates. Choice D is incorrect as pulse rates on infants are usually taken apically in the fifth intercostal space, not the third.
2. Match the abbreviation with the correct definition:
- A. bid: twice a day
- B. tid: three times a day
- C. ac: before meals
- D. pc: after meals
Correct answer: C
Rationale: The abbreviation 'ac' stands for 'ante cibum,' which means 'before meals.' 'Bid' means twice a day. 'Tid' means three times a day, and 'pc' means after meals. When interpreting medical abbreviations, it is crucial to understand their precise meanings to ensure accurate communication and patient care.
3. The nurse is comparing the concepts of religion and spirituality. Which statement describes an appropriate component of one's spirituality?
- A. Belief in and worship of God or gods
- B. Being closely tied to one's ethnic background
- C. Attendance at a specific church or place of worship
- D. A connection with something larger than oneself and belief in transcendence
Correct answer: D
Rationale: Spirituality refers to a connection with something larger than oneself and a belief in transcendence. The other responses do not apply to spirituality. Choice A, 'Belief in and worship of God or gods,' and choice C, 'Attendance at a specific church or place of worship,' are more aligned with religious practices. Choice B, 'Being closely tied to one's ethnic background,' is not a defining aspect of spirituality or religion as it pertains more to cultural identity rather than spiritual beliefs.
4. Which of the following interventions is most appropriate for a client with a diagnosis of Risk for Activity Intolerance?
- A. Perform nursing activities throughout the entire shift
- B. Assess for signs of increased muscle tone
- C. Minimize environmental noise
- D. Teach clients to perform the Valsalva maneuver
Correct answer: C
Rationale: The most appropriate intervention for a client diagnosed with Risk for Activity Intolerance is to minimize environmental noise. Environmental noise can increase the energy demand on the client as they try to manage their responses to stimuli. By reducing excess noise, the nurse helps promote rest and conserves the client's energy, which is crucial in managing activity intolerance. Choice A is incorrect because increasing nursing activities may exacerbate the client's intolerance to activity. Choice B is incorrect as assessing for signs of increased muscle tone does not directly address the issue of activity intolerance. Choice D is incorrect as teaching the Valsalva maneuver is not relevant to managing activity intolerance in this scenario.
5. The healthcare professional is preparing to measure the length, weight, chest, and head circumference of a 6-month-old infant. Which measurement technique is correct?
- A. Measuring the infant's length using a tape measure
- B. Weighing the infant on an electronic standing scale
- C. Measuring the chest circumference at the nipple line with a tape measure
- D. Measuring the head circumference by wrapping the tape measure around the head
Correct answer: C
Rationale: For accurate measurements, specific techniques are required for different parameters in infants. Measuring the chest circumference involves encircling the chest at the nipple line. Length should be measured on a horizontal measuring board. Weight should be measured using a platform-type balance scale. Head circumference measurement entails ensuring the tape is aligned at the eyebrows and prominent frontal and occipital bones for the widest span. Therefore, the correct technique for measuring the chest circumference is at the nipple line with a tape measure. The other options are incorrect because length should be measured on a horizontal board, weight should be measured on a balance scale, and head circumference should be measured around the head, not over the nose and cheekbones.
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