NCLEX : Ethics, Processing, and Care
Study concepts, example questions & explanations for NCLEX
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Example Questions
Example Question #1 : Ethics, Processing, And Care
The nurse cares for a patient hospitalized for 5 days with pneumonia. He is about to be discharged and the nurse is providing discharge instructions to the patient and the family. Which statement made by the patient’s family should most concern the nurse?
“He can eat normally but we have to make sure he has a nutritious diet.”
“He still has to use the incentive spirometer to keep his airways clear and open.”
“He can start doing his chores when he feels better, but shouldn’t overexert himself and should rest a lot.”
“He should stay away from other sick people because his immune system is still weak.”
“He can stop taking the antibiotics when the symptoms are gone.”
“He can stop taking the antibiotics when the symptoms are gone.”
When a patient has an infection and is prescribed antibiotics, the patient should always take the full course of the medication and never discontinue the medication. It is easy for patients to believe they can stop taking the medication when the symptoms are resolved, but the nurse needs to educate the patient to continue the full regimen. The rest of the statements are accurate; the patient must get adequate rest, eat well, use the incentive spirometer, and stay away from others who are sick until he is well.
Example Question #1 : Ethics, Processing, And Care
A 2+ radial pulse is considered to be __________.
An absent pulse
A normal pulse
A bounding pulse
A weak pulse
A normal pulse
The following scale applies to the amplitude of a pulse when palpated at the radial artery:
3+ is an increased or bounding pulse
2+ is a normal pulse
1+ is a weak pulse
0 is an absent pulse
Example Question #2 : Ethics, Processing, And Care
Which of the following locations is most appropriate for assessing the pulse of an infant?
Brachial artery
Popliteal artery
Radial artery
Carotid artery
Brachial artery
The most appropriate location for assessing the pulse of an infant is the brachial artery, which travels from the axilla down the ventral surface of the upper arm to the cubital fossa. The popliteal and radial pulses are difficult to palpate on an infant due to their size, and the carotid artery can be difficult to palpate due to an infant's shorter, thicker neck.
Example Question #1 : Procedures And Care
Which of the following is a normal adult respiratory rate?
Normal adult respiratory rate is 12-20 breaths per minute. A respiratory rate below 12 is defined as bradypnea, while a respiratory rate above 20 is considered tachypnea.
Example Question #2 : Ethics, Processing, And Care
What is a normal respiratory rate for an infant under 1 year of age?
30-60 breaths per minute
10-20 breaths per minute
20-30 breaths per minute
60-90 breaths per minute
30-60 breaths per minute
Infants have the highest respiratory rate of any age group. A normal infant respiratory rate is 30-60 breaths per minute.
Example Question #4 : Procedures And Care
How might an overlarge cuff affect a blood pressure reading?
The reading may be unstable
The reading would be artificially high
There would be no significant effect
The reading would be artificially low
The reading would be artificially low
An overlarge blood pressure cuff will often result in a blood pressure reading that is artificially low. It is important that the nurse chooses the appropriate blood pressure cuff size for each individual patient.
Example Question #1 : Ethics, Processing, And Care
While assessing a patient's blood pressure, what part of the stethoscope should be placed against the patient's antecubital fossa: the bell, or the diaphragm?
The diaphragm should be used first, then the bell
The bell should be used first, then the diaphragm
The diaphragm
The bell
The diaphragm
When taking a patient's blood pressure, the diaphragm alone should be used to listen at the antecubital fossa. The bell, used for low-pitched sounds, would not give the examiner accurate enough information to assess systolic or diastolic pressure.
Example Question #1 : Taking And Interpreting Vitals
Which of the following would be considered a normal adult blood pressure?
132/88 mmHg
124/84 mmHg
88/56 mmHg
110/72 mmHg
110/72 mmHg
Normal adult blood pressure is anywhere from 90-120 mmHg systolic over 60-80 mmHg diastolic. 120-140 mmHg over 80-90 mmHg would be considered pre-hypertension, while anything over that would be considered either stage I or stage II hypertension.
Example Question #2 : Taking And Interpreting Vitals
What is a normal respiratory rate for a child aged 1-6 years old?
24-34 breaths per minute
12-24 breaths per minute
34-44 breaths per minute
36-54 breaths per minute
24-34 breaths per minute
A normal respiratory rate in a child aged 1-6 years is 24-34 breaths per minute. This is significantly higher than an adult normal respiratory rate, which is 12-20 breaths per minute.
Example Question #2 : Procedures And Care
What is a normal heart rate for an infant under 1 year old in beats per minute (bpm)?
160-240 bpm
100-160 bpm
60-100 bpm
30-60 bpm
100-160 bpm
Infants have the highest heart rate of any age group. Normal heart rate for an infant under one year of age is 100-160 bpm.
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