a parent calls the pediatric clinic and is frantic about the bottle of cleaning fluid her child drank for 20 minutes which of the following is the mos

NCLEX-RN

Exam Cram NCLEX RN Practice Questions

1. A parent calls the pediatric clinic and is frantic about the bottle of cleaning fluid her child drank for 20 minutes. Which of the following is the most important instruction the nurse can give the parent?

A. This too shall pass.
B. Take the child immediately to the ER
C. Contact the Poison Control Center quickly
D. Give the child syrup of ipecac

Correct answer: C

Rationale: In situations where a child has ingested a potentially harmful substance, contacting the Poison Control Center quickly is crucial. The Poison Control Center can provide specific guidance tailored to the child's situation, which can include whether immediate medical attention is necessary or if any actions need to be taken at home. Option A, 'This too shall pass,' is not appropriate as it dismisses the seriousness of the situation. Option B, 'Take the child immediately to the ER,' may not always be the best course of action without guidance from experts. Option D, 'Give the child syrup of ipecac,' is outdated advice and not recommended as a first response to poisoning incidents.

2. The nurse should wash from the ________________________ when washing a patient's eye area.

A. outer canthus to the inner canthus
B. inner canthus to the outer canthus
C. internal nares to the external nares
D. external nares to the internal nares

Correct answer: B

Rationale: When washing a patient's eye area, it is important to start from the inner canthus (closest to the nose) and move towards the outer canthus. This direction prevents any contaminants or debris from the outer area of the eye from moving towards the inner, more sensitive area. Choices C and D are incorrect as they pertain to the nasal passages (nares), which are not relevant when washing the eye area.

3. The nurse is preparing to assess a hospitalized patient who is experiencing significant shortness of breath. How should the nurse proceed with the assessment?

A. Have the patient lie down to obtain an accurate cardiac, respiratory, and abdominal assessment.
B. Obtain a thorough history and physical assessment from the patient's family member.
C. Immediately perform a complete history and physical assessment to obtain baseline information.
D. Examine the body areas relevant to the problem and complete the rest of the assessment after the problem has resolved.

Correct answer: D

Rationale: When assessing a patient experiencing significant shortness of breath, it is crucial to prioritize the evaluation of areas directly related to the problem. Having the patient lie down may exacerbate the breathing difficulty. Therefore, the nurse should focus on examining the body areas pertinent to the issue, such as the respiratory and cardiac systems. Completing the rest of the assessment can be deferred until after addressing the immediate problem. Obtaining a complete history or involving family members should come after addressing the acute issue to ensure the patient's safety and comfort.

4. Which body plane divides the body into right and left sides?

A. Frontal Plane
B. Medial Plane
C. Median Plane
D. Transverse Plane

Correct answer: C

Rationale: The correct answer is the Median Plane, also known as the sagittal plane. It divides the body into right and left sides. The Frontal Plane, or coronal plane, divides the body into front and back sections. The Transverse Plane divides the body into superior (upper) and inferior (lower) sections. Therefore, choices A, B, and D are incorrect as they do not specifically divide the body into right and left sides.

5. When performing CPR, at what rate should chest compressions be applied?

A. 100 per minute
B. 60 per minute
C. As quickly as possible
D. 200 per minute

Correct answer: A

Rationale: During CPR, chest compressions should be applied at a rate of 100 compressions per minute in order to effectively circulate blood and oxygen to vital organs. Option A, '100 per minute,' is the correct answer as it aligns with the recommended compression rate in CPR guidelines. Option B, '60 per minute,' is incorrect as it is too slow and may not provide adequate circulation. Option C, 'As quickly as possible,' is vague and does not specify the recommended compression rate. Option D, '200 per minute,' is incorrect as it exceeds the recommended rate and may not be as effective in maintaining perfusion.