each small square on the ekg paper is

NCLEX-RN

NCLEX RN Predictor Exam

1. Each small square on the EKG paper is:

A. 0.04 seconds long and 5mm tall
B. 0.2 seconds long and 5mm tall
C. 0.04 seconds long and 20mm tall
D. 0.04 seconds long and 1mm tall

Correct answer: D

Rationale: Each small square on an EKG paper represents 0.04 seconds long and 1mm tall. This standardization is essential for accurate measurements. One large square on EKG paper consists of 5 small squares in length and 5 small squares in height, which equals 0.2 seconds long and 5mm tall (0.5 mV). Choice A is incorrect because while the duration is correct, the height mentioned is not accurate. Choice B is incorrect as it provides the correct height but the duration is inaccurate. Choice C is incorrect as the height mentioned is exaggerated, and the duration is correct but the height is not. Therefore, the correct answer is 0.04 seconds long and 1mm tall.

2. 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.

3. A client is suspected of having carbon monoxide poisoning. Which of the following symptoms are associated with this condition?

A. Red rash across the trunk and extremities
B. Nausea, vomiting, seizures
C. Flushing of the face and neck
D. Abdominal pain radiating to the back

Correct answer: B

Rationale: The correct answer is 'Nausea, vomiting, seizures.' Carbon monoxide poisoning can present with symptoms such as headache, dizziness, weakness, nausea, vomiting, and confusion. Severe cases can progress to seizures, coma, and even death. It is crucial for healthcare providers to recognize these symptoms promptly to initiate appropriate treatment. Choices A, C, and D are incorrect because a red rash, flushing of the face and neck, and abdominal pain radiating to the back are not typically associated with carbon monoxide poisoning. It is essential to be aware of the common manifestations of carbon monoxide poisoning to ensure timely intervention and prevent adverse outcomes.

4. A student is late for an appointment and has rushed across campus to the health clinic. How should the nurse proceed?

A. Allow 5 minutes for the student to relax and rest before checking their vital signs.
B. Check the blood pressure in both arms, expecting a difference in the readings due to the recent exercise.
C. Immediately monitor the student's vital signs upon arrival at the clinic and then 5 minutes later, recording any differences.
D. Check the student's blood pressure in the supine position to provide a more accurate reading and allow the student to relax at the same time.

Correct answer: A

Rationale: To ensure an accurate blood pressure reading, it is important for the student to be in a relaxed state. Allowing at least a 5-minute rest period helps reduce anxiety and provides a valid blood pressure measurement. Checking the blood pressure in both arms is unnecessary unless there is a specific reason to suspect an issue, and recent exercise should not significantly impact the readings. Monitoring vital signs immediately upon arrival may not yield accurate results due to the rush and anxiety of the student. Checking blood pressure in the supine position is not necessary in this scenario and does not provide a more accurate reading.

5. A client who complains of nausea and seems anxious is admitted to the nursing unit. The nurse should take which of the following actions regarding completion of the admission interview?

A. Help the client to get settled and conduct the interview the next morning when the client is rested
B. Conduct the interview immediately, directing the majority of the questions to the client
C. Conduct the interview as soon as uninterrupted time is available to address the client's concerns
D. Ask the charge nurse to interview the client while the admitting nurse calls the doctor for anti-nausea and anti-anxiety medication

Correct answer: C

Rationale: When dealing with a client who is experiencing nausea and anxiety, it is important to promptly conduct the admission interview to address their concerns. This allows for the collection of accurate data while attending to the client's immediate needs. Delaying the interview until the next morning (Choice A) may not be in the best interest of the client as timely assessment and intervention are essential. Directing questions to the client's spouse (Choice B) may not provide accurate information from the client themselves. Asking another nurse to conduct the interview while administering medications (Choice D) does not prioritize building a therapeutic relationship with the client, which is crucial in addressing their concerns and providing holistic care.