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

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?

A. Notify the physician.
B. Record this finding as normal.
C. Check the child's blood pressure and note any variation with respiration.
D. Document that this child has bradycardia and continue with the assessment.

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. What is the anatomic structure located in the middle of the heart that separates the right and left ventricles?

A. Septum
B. Sputum
C. Separator
D. None of the above

Correct answer: A

Rationale: The correct answer is the septum. The septum is a structure located in the middle of the heart that separates the right and left ventricles. It plays a crucial role in maintaining the separation between the two ventricles to ensure efficient blood flow. The other choices, 'Sputum' and 'Separator,' are incorrect as they do not refer to the anatomic structure in the heart that serves this specific function. 'Sputum' is a term used to describe phlegm or mucus, not an anatomical structure, and 'Separator' is a generic term that does not specifically identify the cardiac structure mentioned in the question.

3. A healthcare provider attempts to plug in a sequential compression device when they notice a tingling sensation in their hands while touching the cord. What is the next action of the healthcare provider?

A. Attempt to plug the device into a different outlet
B. Inspect the cord for damage; if none is present, continue to use the device
C. Discontinue the device and send it to the maintenance department for inspection
D. Notify the supervisor that the unit is at risk of an electrical fire

Correct answer: C

Rationale: Feeling a tingling sensation when touching an electrical cord is a warning sign that the device may be malfunctioning. This sensation indicates a potential electrical current leak, which could pose a risk of harm. The correct action is to immediately discontinue the use of the device and send it to the maintenance department for inspection. Continuing to use the device without addressing the issue could lead to electric shock or fire hazards. Trying to plug the device into a different outlet does not address the underlying problem of potential device malfunction. Notifying the supervisor about the risk of an electrical fire is important, but the immediate action should be to stop using the device and have it inspected by maintenance professionals. Therefore, the best course of action is to discontinue the device and ensure it is checked thoroughly before further use.

4. When teaching a patient to use the three-point gait technique of crutch use:

A. The injured leg moves ahead at the same time as both crutches.
B. One crutch moves at a time and is then followed by the injured leg.
C. Both crutches move ahead at the same time followed by both legs at the same time.
D. None of the above are correct.

Correct answer: A

Rationale: The correct technique for a three-point gait involves the injured leg moving simultaneously with both crutches, followed by the uninjured leg. This gait pattern is utilized when the patient is unable to bear full weight on one of their legs. Choice A accurately describes the appropriate sequence of movements for the three-point gait technique. Choices B and C do not accurately reflect the correct pattern of movement during the three-point gait technique, making them incorrect. Choice D is incorrect as there is a correct option among the choices provided.

5. Which of the following is an example of emotional abuse?

A. A slap to the person's hand
B. Threatening the person
C. Ignoring and isolating a person
D. Leaving a patient soiled for hours

Correct answer: C

Rationale: Emotional abuse involves behaviors that harm an individual's self-worth and emotional well-being. Threatening someone instills fear and causes psychological distress, making it a clear example of emotional abuse. Choices A, C, and D involve physical abuse, neglect, and neglect of care, respectively, rather than emotional abuse. A slap to the person's hand constitutes physical abuse, ignoring and isolating a person is neglectful behavior, and leaving a patient soiled for hours falls under neglect of care.