when assessing the pulse of a 6 year old patient the nurse notices that the heart rate varies with the respiratory cycle speeding up at the peak of in
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Nursing Elites

NCLEX-RN

Exam Cram NCLEX RN Practice Questions

1. When assessing the pulse of a 6-year-old patient, the nurse notices that the heart rate varies with the respiratory cycle, speeding up at the peak of inspiration and slowing to normal with expiration. What action would the nurse take next?

Correct answer: B

Rationale: The correct action for the nurse to take next is to record this finding as normal. Sinus dysrhythmia, characterized by heart rate variation with the respiratory cycle, is commonly found in children and young adults. The heart rate speeds up at the peak of inspiration and slows to normal with expiration. This phenomenon is a normal variant and does not require any intervention. There is no need to notify the physician as this finding is within the expected range for this age group. Checking the child's blood pressure for variations with respiration or documenting the child as having bradycardia would not be appropriate in this case, as sinus dysrhythmia is a normal physiological response.

2. A triage nurse has four clients arrive in the emergency department within 15 minutes. Which client should the triage nurse send back to be seen first?

Correct answer: B

Rationale: The correct answer is the teenager who suffered singed facial hair while camping. This client is in the greatest danger with a potential risk of respiratory distress. Singed facial hair indicates exposure to heat or fire in close range, which could have caused serious damage to the interior of the lungs. It's crucial to prioritize this client as the interior lining of the lungs has no nerve fibers, so swelling may not be immediately noticeable. The other choices, while concerning, do not present an immediate life-threatening situation. The infant's condition may be serious but does not pose an immediate danger of respiratory distress. The elderly client's symptoms could indicate gastrointestinal issues, which are important but not as urgent as potential respiratory compromise. The middle-aged client's pain behind the right scapula, while uncomfortable, does not indicate an acute life-threatening condition requiring immediate attention.

3. The Rule of Nines is used to:

Correct answer: A

Rationale: The Rule of Nines is used to assess the amount of body surface that has been burned. Most body areas are divided out based on 9%, with the exception of the genitalia, which is only 1%.

4. What is the primary purpose of a patient care meeting or conference?

Correct answer: B

Rationale: The primary purpose of a patient care meeting or conference is to determine how the healthcare team can best meet the patient's needs. These meetings involve discussions among healthcare professionals to tailor the care plan to the specific needs and preferences of the patient. Option A is incorrect because financial discussions are generally not the primary focus of patient care meetings. Option C is incorrect as the patient's physical status is usually already known and is not the primary purpose of the meeting. Option D is incorrect as psychosocial aspects, while important, are not the sole focus of the meeting, which is primarily about addressing the patient's overall needs and preferences.

5. Which of the following situations indicates the need to file an incident report?

Correct answer: D

Rationale: An incident report is necessary for documenting unexpected events that occur in a healthcare setting. Situations that warrant filing an incident report include client accidents, medication errors, security problems, or disruptive behaviors that involve clients, families, or visitors. In this scenario, when a client's spouse displays disruptive behavior and is asked to leave the premises, it is essential to document this incident to ensure a record of the event and its resolution. Choices A, B, and C do not involve disruptive behavior or safety concerns that would require an incident report to be filed.

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