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. When should you wear gloves?
- A. preparing infant formula for a newborn baby
- B. transferring breast milk into a baby bottle
- C. knocking on a patient's door
- D. opening a patient's door
Correct answer: B
Rationale: You must wear gloves when transferring breast milk into a baby bottle because breast milk is considered a bodily fluid. It is essential to avoid direct contact to prevent contamination. When preparing infant formula, gloves are not required as formula is not a bodily fluid. Knocking on or opening a patient's door does not involve direct contact with bodily fluids, so gloves are unnecessary in those situations.
3. An 86-year-old client with decreased visual acuity who uses a cane for mobility requires fall prevention education. What should the nurse teach this client to reduce the risk of falling at home?
- A. Take off shoes while in the house and wear only socks
- B. Limit activities to the lower level of the home
- C. Keep a lamp near the door of every room
- D. Install non-slip pads in the shower or bathtub
Correct answer: D
Rationale: To reduce the risk of falling at home for an elderly client with decreased visual acuity and using a cane for mobility, installing non-slip pads in the shower or bathtub is crucial. This measure helps prevent slips and falls in areas where water accumulation may occur. While taking off shoes and wearing socks may seem comfortable, it increases the risk of slipping. Limiting activities to the lower level of the home may restrict the client's independence and quality of life unnecessarily. Keeping a lamp near the door of every room may improve visibility but does not directly address the risk of falls associated with mobility and visual acuity issues.
4. The mitral valve is synonymous with the term:
- A. Left ventricle
- B. Right atrium
- C. Bicuspid valve
- D. Tricuspid valve
Correct answer: C
Rationale: The mitral valve, also known as the bicuspid valve, is located between the left atrium and the left ventricle, regulating blood flow from the left atrium into the left ventricle. The term 'bicuspid' refers to the valve's two cusps or leaflets. This distinguishes it from the tricuspid valve (Choice D), which has three cusps, making Choice D incorrect. The left ventricle (Choice A) and right atrium (Choice B) are not synonymous with the mitral valve. Therefore, the correct answer is C: Bicuspid valve.
5. What does the medical term 'diaphoresis' mean?
- A. Profuse vomiting
- B. Profuse sweating
- C. Gasping for air
- D. None of the above
Correct answer: B
Rationale: The correct answer is B: Profuse sweating. Diaphoresis is a medical term that refers to excessive sweating. It is commonly seen in emergency situations such as heart attacks or diabetic episodes. Choice A, 'Profuse vomiting,' is incorrect as diaphoresis is not related to vomiting. Choice C, 'Gasping for air,' is also incorrect as it refers to difficulty breathing, not sweating. Choice D, 'None of the above,' is incorrect as diaphoresis specifically relates to sweating.
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