NCLEX NCLEX-RN
Exam Cram NCLEX RN Practice Questions
1. The nurse is assessing children in a pediatric clinic. Which statement is true regarding the measurement of blood pressure in children?
- A. Blood pressure guidelines for children are based on age.
- B. Phase II Korotkoff sounds are the best indicator of systolic blood pressure in children.
- C. Using a Doppler device is recommended for accurate blood pressure measurements until adolescence.
- D. The disappearance of phase V Korotkoff sounds can be used for the diastolic reading in children.
Correct answer: The disappearance of phase V Korotkoff sounds can be used for the diastolic reading in children.
Rationale: The disappearance of phase V Korotkoff sounds can be used for the diastolic reading in children, as well as in adults. Blood pressure guidelines for children are based on more than just age, but also sex and height. Phase I Korotkoff, not Phase II, is the best indicator of systolic blood pressure. The true statement regarding the measurement of blood pressure in children is that the disappearance of phase V Korotkoff sounds can be used for the diastolic reading in children, as well as in adults.
2. The Rule of Nines is used to:
- A. determine the amount of the body surface that has been burned.
- B. assess the level of oxygen saturation in a body that has been burned.
- C. determine the level of tissue damage that has occurred in a burn.
- D. None of the above.
Correct answer: determine the amount of the body surface that has been burned.
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%.
3. What would be the first step for a nurse in efficiently addressing a situation of moral dilemma?
- A. Helping the client make a moral decision
- B. Recognizing one’s own moral development level
- C. Abiding by the decision of the hospital authority
- D. Having one’s own opinion that differs from the health care team
Correct answer: Recognizing one’s own moral development level
Rationale: The correct first step for a nurse in efficiently addressing a moral dilemma is to recognize their own moral development level. By understanding their own moral reasoning, a nurse can effectively navigate moral challenges. Helping clients make moral decisions comes after the nurse has assessed their own moral standpoint. Abiding by hospital authority decisions may not always align with a nurse's ethical beliefs, so it's crucial for a nurse to form their own opinions and communicate concerns with the healthcare team to ensure ethical practice and decision-making.
4. After a client has a spontaneous abortion at 12 weeks’ gestation, the nurse notes that both she and her partner are visibly upset and crying. Which statement would be a therapeutic response?
- A. ''I’ll be here if you want to talk.''
- B. ''Try to relax—it’ll speed up the healing process.''
- C. ''With any luck, you’ll get pregnant again soon.''
- D. ''It’s best that this happened early rather than having the baby die after it was born.''
Correct answer: ''I’ll be here if you want to talk.''
Rationale: A therapeutic response in this situation is to offer support and empathy. Saying, 'I’ll be here if you want to talk' gives the client and her partner the opportunity to express their emotions and seek comfort. It acknowledges their distress and assures them of the nurse's availability. Choice B, advising to relax to speed up the healing process, dismisses their current emotions and may hinder open communication. Choice C, suggesting getting pregnant again soon, minimizes their grief over the loss and may not be what the couple needs to hear at that moment. Choice D, stating it's best that the miscarriage happened early, is insensitive as it invalidates the couple's feelings of loss and grief. Grieving is a natural process, and the timing of the loss does not diminish its significance.
5. Which intervention would the nurse use to provide emotional support for a resident in a nursing home who recently immigrated from another country?
- A. Offer choices consistent with the resident's heritage.
- B. Assist the resident in adjusting to the nursing home culture.
- C. Ensure that the resident is treated respectfully like the other residents.
- D. Correct any misconceptions the resident may have about appropriate health practices.
Correct answer: Offer choices consistent with the resident's heritage.
Rationale: When providing emotional support to a resident in a nursing home who recently immigrated from another country, it is essential for the nurse to offer choices that align with the resident's heritage. This approach respects the resident's cultural beliefs and practices, promoting a sense of familiarity and comfort. Assisting the resident in adjusting to the nursing home culture is important but may not address the specific emotional support needed. While ensuring that the resident is treated respectfully is crucial, offering choices consistent with the resident's heritage goes a step further by acknowledging and valuing the resident's cultural background. Correcting any misconceptions about health practices is essential, but in this context, emotional support through cultural sensitivity takes precedence.
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