a child is admitted to the hospital several days after stepping on a sharp object that punctured her athletic shoe and entered the flesh of her foot t

NCLEX-RN

Exam Cram NCLEX RN Practice Questions

1. A child is admitted to the hospital several days after stepping on a sharp object that punctured her athletic shoe and entered the flesh of her foot. The physician is concerned about osteomyelitis and has ordered parenteral antibiotics. Which of the following actions is done immediately before the antibiotic is started?

A. The admission orders are written.
B. A blood culture is drawn.
C. A complete blood count with differential is drawn.
D. The parents arrive.

Correct answer: B

Rationale: Before starting antibiotics, a blood culture should be drawn to identify the causative organism. This step is crucial as antibiotics may interfere with the identification process. Drawing a complete blood count with differential or writing admission orders are important steps in patient care but are not as critical as obtaining a blood culture to guide appropriate antibiotic therapy. The arrival of the parents is not directly related to the immediate action required before starting antibiotics in this scenario.

2. The nurse is assessing the vital signs of a 3-year-old patient who appears to have an irregular respiratory pattern. How would the nurse assess this child's respirations?

A. Respirations should be counted for 1 full minute.
B. Child's pulse and respirations should be simultaneously checked for 30 seconds and then multiplied by 2.
C. Child's respirations should be checked for a minimum of 5 minutes to identify any variations in his or her respiratory pattern.
D. Patient's respirations should be counted for 15 seconds and then multiplied by 4.

Correct answer: A

Rationale: To accurately assess a child's respiratory pattern, the nurse should count respirations for a full minute. This duration provides a comprehensive view of the child's breathing pattern, ensuring abnormalities are not missed. Counting for only 30 seconds may not capture irregularities effectively. Checking respirations for 5 minutes is excessive and unnecessary for a routine assessment. Counting for 15 seconds and multiplying by 4 is not as precise as a full-minute count. Pulse and respirations should not be checked simultaneously; instead, the nurse should count respirations unobtrusively while appearing to take the child's pulse. Therefore, the correct approach is to count the child's respirations for 1 full minute to obtain an accurate assessment.

3. Which of the following is an example of emotional neglect?

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: The correct answer is ignoring and isolating a person. Emotional neglect involves failing to meet the emotional needs of individuals, which can include ignoring their feelings and isolating them. Choices A, B, and D involve physical aggression, verbal threats, and neglect of physical care, respectively. These actions may be forms of abuse or neglect, but they do not specifically relate to emotional neglect as described in the question.

4. While caring for Mrs. Thomas, you see a notation on the nursing care plan that states 'ambulate at least 10 yards qid'. This patient will be assisted with ambulation at which of the following times?

A. 10:00 AM
B. 10 am and 2 pm
C. 10 am and 2 pm
D. 10 am, 2 pm, 6 pm, and 10 pm

Correct answer: D

Rationale: The correct answer is to assist the patient with ambulation at 10 am, 2 pm, 6 pm, and 10 pm as qid stands for four times per day. This schedule is commonly followed in healthcare facilities to ensure regular ambulation and exercise for the patient. Choices A, B, and C do not cover all the specified times for ambulation as indicated by the qid notation on the care plan.

5. Why should a palpated pressure be performed before auscultating blood pressure?

A. To more clearly hear the Korotkoff sounds.
B. To detect the presence of an auscultatory gap.
C. To avoid missing a falsely elevated blood pressure.
D. To more readily identify phase IV of the Korotkoff sounds.

Correct answer: B

Rationale: Performing a palpated pressure before auscultating blood pressure helps in detecting the presence of an auscultatory gap. An auscultatory gap is a period during blood pressure measurement when Korotkoff sounds temporarily disappear before reappearing. Inflation of the cuff 20 to 30 mm Hg beyond the point where a palpated pulse disappears helps in identifying this gap. This technique ensures accurate blood pressure measurement by preventing the underestimation of blood pressure values. The other options are incorrect because palpating the pressure is not primarily done to hear Korotkoff sounds more clearly, avoid missing falsely elevated blood pressure, or readily identify a specific phase of Korotkoff sounds.