NCLEX : NCLEX

Study concepts, example questions & explanations for NCLEX

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Example Questions

Example Question #2 : Procedures And Care

What is a normal heart rate for an infant under 1 year old in beats per minute (bpm)?

Possible Answers:

160-240 bpm

100-160 bpm

60-100 bpm

30-60 bpm

Correct answer:

100-160 bpm

Explanation:

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. 

Example Question #672 : Nclex

What is a normal heart rate for a school aged child (6-12 years of age) in beats per minute (bpm)?

Possible Answers:

100-140 bpm

70-120 bpm

120-160 bpm

50-70 bpm

Correct answer:

70-120 bpm

Explanation:

Normal heart rate for a child aged 6-12 is 70-120 bpm. This is moderately higher than normal heart rate for an adult, which is 60-100 bpm. 

Example Question #671 : Nclex

What is the correct way to determine proper blood pressure cuff size?

Possible Answers:

The inflatable bladder should cover approximately 80% of the circumference of the forearm while its width should cover approximately 40%

The inflatable bladder should cover approximately 40% of the circumference of the forearm while its width should cover approximately 80%

The vinyl covering should be able to wrap at least twice around the forearm

The inflatable bladder should cover approximately 50% of the circumference of the forearm while its width should cover approximately 20%

Correct answer:

The inflatable bladder should cover approximately 80% of the circumference of the forearm while its width should cover approximately 40%

Explanation:

Proper cuff size is very important for accurate blood pressure assessment. The correct way to determine proper blood pressure cuff size is to wrap the cuff around the arm, then note the area covered by the inflatable bladder. The inflatable bladder should cover approximately 80% of the circumference of the forearm while its width should cover approximately 40%. 

Example Question #11 : Taking And Interpreting Vitals

A stethoscope has two components to the chest piece. These are called the __________ and the __________.

Possible Answers:

bell . . . diaphragm

cone . . . disc

cone . . . diaphragm

bell . . . disc

Correct answer:

bell . . . diaphragm

Explanation:

The chest-piece of the stethoscope is made up of two components designed for auscultation: the bell and the diaphragm. The bell is dome-shaped and used for auscultation of low-pitched sounds, while the diaphragm is used to auscultate high-pitched sounds.

Example Question #12 : Taking And Interpreting Vitals

A nurse takes a patient's blood pressure and records it at 146/92 mmHg. This is the patient's first visit to the clinic and they have no past medical records available. Would this patient be diagnosed with hypertension?

Possible Answers:

No, there is not enough information

Yes, this is stage I hypertension

No, this is within the normal range

Yes, this is malignant hypertension

Correct answer:

No, there is not enough information

Explanation:

A patient with a one-time high blood pressure reading can not be diagnosed as hypertensive. A diagnosis of hypertension requires at least three measurements of blood pressure over 140/90 mmHg on at least two separate visits to health care provider. 

Example Question #11 : Taking And Interpreting Vitals

A patient with a blood pressure reading of 168/102 mmHg on three or more occasions would be diagnosed with what stage of hypertension?

Possible Answers:

Stage III hypertension

Stage II hypertension

Stage I hypertension

Prehypertension

Correct answer:

Stage II hypertension

Explanation:

Stage II hypertension is defined as a blood pressure equal to or greater than 160 mmHg systolic over 100 mmHg diastolic, taken at three different times on at least two separate occasions. Stage I hypertension is systolic blood pressure of 140-160 mmHg or diastolic blood pressure of 90-100 mmHg, while prehypertension is defined as a systolic blood pressure of 120-140 mmHg or diastolic blood pressure of 80-90 mmHg.

Example Question #15 : Ethics, Processing, And Care

Which of the following is not a normal part of taking a patient's vitals?

Possible Answers:

Overall visual appearance

Pulse

All of these are part of taking a patient's vitals

Temperature

Correct answer:

All of these are part of taking a patient's vitals

Explanation:

While most examiners remember to take the pulse, temperature, and blood pressure while assessing their patient's vitals, overall visual appearance is also an important part of an individuals vitals. Does the patient appear ill? Anxious? Are there any noticeable issues with hygiene or bizarre dress or movements? Are there any signs of pallor, jaundice, or cyanosis? All of these observations can be quickly noted in a patient's chart when taking vitals.

Example Question #12 : Taking And Interpreting Vitals

The pulse of your patient is 120 beats per minute. What is the appropriate term for this finding?

Possible Answers:

Tachycardia

Normal heart rate

Bradycardia

Asystole

Aortic stenosis

Correct answer:

Tachycardia

Explanation:

Tachycardia is the term used to describe a faster than normal heart rate. A heart rate of more than 100 beats per minute is considered tachycardic. Bradycardia is used to describe a slower than normal heart rate. Less than 60 beats per minute is considered bradycardia.

Example Question #11 : Taking And Interpreting Vitals

The physician on call pages you to ask if the patient you are taking care of is afebrile. Which of the following vital signs would you find in an afebrile patient?

Possible Answers:

Temperature of 97.9 degrees Fahrenheit

Blood pressure of 105 over 89

Temperature of 103.2 degrees Fahrenheit

Respiratory rate greater than 25 breaths per minute

Heart rate of 105 beats per minute

Correct answer:

Temperature of 97.9 degrees Fahrenheit

Explanation:

Afebrile is a term used to describe a patient who does not have a fever. Clinically, a fever is defined as a temperature greater than 100.4 Fahrenheit. Blood pressure, heart rate, and respiratory rate do not tell you if the patient has a fever.

Example Question #11 : Procedures

A 39-year-old man presents to the ER with weakness, confusion, and vertigo. His heart rate is 91 and bounding, blood pressure is , temperature is , and blood glucose is . He is non-diabetic, he is not on any medication, and he denies recreational drug use. Which of the following is the most likely cause of his symptoms?

Possible Answers:

Infection

Hypertension

Panic attack

Hypoglycemia

Correct answer:

Hypoglycemia

Explanation:

The most likely cause of his symptoms is hypoglycemia, which is defined as a blood glucose below  in a non-diabetic patient. The symptoms of hypoglycemia include altered consciousness, tremors, weakness, vertigo, headaches, heart palpitations, and a bounding pulse.

A temperature of  is not considered abnormal as it may reflect a normal variation in body temperature.

His blood pressure is slightly elevated, but it is unclear whether this is typical for him or whether this represents a significant change from his normal blood pressure. Regardless it would not likely be sufficiently elevated to cause his symptoms.

It is also possible he may be experiencing a panic attack, but in the presence of his depressed blood sugar (and absence of signs of anxiety), hypoglycemia is the most likely cause of his symptoms.

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