NCLEX RN Exam Actual Questions & Answers Bank with Rationales 100% Verified Q&A

1. 1. Question Category: Health Promotion and Maintenance A pediatric nurse is performing a routine assessment of a one-month-old infant during a well-baby visit at the primary care clinic. The infant’s mother reports no concerns and states that the baby has been feeding well and has had regular bowel movements. Upon assessment, which of the following findings warrants further investigation by the nurse? Select all that apply. o A. Abdominal respirations o B. Irregular breathing rate o C. Inspiratory grunt o D. Increased heart rate with crying o E. Nasal flaring o F. Cyanosis o G. Asymmetric chest movement Correct Answers: C, E, F, & G  Option C. Grunting occurs when an infant attempts to maintain an adequate functional residual capacity in the face of poorly compliant lungs by partial glottic closure. As the infant prolongs the expiratory phase against this partially closed glottis, there is a prolonged and increased residual volume that maintains the airway opening and also an audible expiratory sound.  Option E: Nasal flaring occurs when the nostrils widen while breathing and is a sign of troubled breathing or respiratory distress.  Option F: Cyanosis refers to the bluish discoloration of the skin and indicates a decrease in oxygen attached to the red blood cells in the bloodstream.  Option G: Asymmetric chest movement occurs when the abnormal side of the lungs expands less and lags behind the normal side. This indicates respiratory distress.  Option A: Abdominal respiration is normal among infants and young children. Since their intercostal muscles are not yet fully developed, they use their abdominal muscles much more to pull the diaphragm down for breathing.  Option B: Newborns can have irregular breathing patterns ranging from 30 to 60 breaths per minute with short periods of apnea (15 seconds).  Option D: An increase in heart rate is normal for an infant during activity (including crying). Fluctuations in heart rate follow the changes in the newborn’s behavioral state – crying, movement, or wakefulness corresponds to an increase in heart rate. 2. 2. Question Category: Pharmacological and Parenteral Therapies A nurse is to administer meperidine hydrochloride (Demerol) 100 mg, atropine sulfate (Atropisol) 0.4 mg, and promethazine hydrochloride (Phenergan) 50 mg IM to a preoperative client. List the order in which the nurse must carry out the following actions prior to the administration of preoperative medications. View Answers:  Place the call bell within reach  Have the client empty bladder  Instruct the client to remain in bed  Raise the side rails on the bed Correct order is shown above. 4. Have the client empty the bladder. The first step in the process is to have the client void prior to administering the pre-operative medication. If the client does not have a catheter, it is important to empty the bladder before receiving preoperative medications to prevent bladder injury (especially in pelvic surgeries). Else, a straight catheter or an indwelling catheter may be ordered to ensure the bladder is empty. 5. Instruct the client to remain in bed. Preoperative medications can cause drowsiness and lightheadedness which may put the client at risk for injury. 6. Raise the side rails on the bed. Raising the side rails on the bed helps prevent accidental falls and injury when the client decides to get out of the bed without assistance. 7. Place the call bell within reach. Call bells should always be within the reach of a client. 3. 3. Question Category: Health Promotion and Maintenance A 32-year-old pregnant woman comes to the clinic for her prenatal visit. The nurse gathers data about her obstetric history, which includes 3-year-old twins at home and a miscarriage 10 years ago at 12 weeks gestation. How would the nurse accurately document this information? Fill in the blanks. o Answer: Gravida (3) para (1) Correct Answer: Gravida 3 para 1 Gravida is the number of confirmed pregnancies and each pregnancy is only counted one time, even if the pregnancy was a multiple gestation (i.e., twins, triplets). Para (parity) indicates the total number of pregnancies that have reached viability (20 weeks) regardless of whether the infants were born alive. Thus, for this woman, she is now pregnant, had 2 prior pregnancies, and 1 viable birth (twins). Learn more about the GTPAL system here. 4. 4. Question Category: Reduction of Risk Potential The nurse educates individuals on the risk factors for developing hypertension during a community health fair. Which of the following individuals are at the MOST significant risk for developing hypertension? o A 45-year-old African-American attorney with a family history of hypertension, who has a sedentary lifestyle and consumes a diet high in sodium. o A 60-year-old Asian-American shop owner with a BMI of 28, who has wellmanaged type 2 diabetes and engages in regular physical activity. o A 40-year-old Caucasian nurse who is a vegetarian, has a healthy BMI, and is a non-smoker but reports high levels of work-related stress. o A 55-year-old Hispanic teacher who smokes occasionally, has a healthy BMI, and participates in a moderate-intensity exercise program. Correct Answer: A 45-year-old African-American attorney with a family history of hypertension, who has a sedentary lifestyle and consumes a diet high in sodium. African-American adults have a higher prevalence of hypertension compared to other racial and ethnic groups in the United States. This individual also has a family history of hypertension, a sedentary lifestyle, and a diet high in sodium, which are all risk factors for hypertension. Therefore, this individual is at the greatest risk for developing hypertension among the given choices.  Option B. 60-year-old Asian-American shop owner: Although age is a risk factor for hypertension, this individual has well-managed type 2 diabetes and engages in regular physical activity. Their BMI of 28 suggests being overweight, but the combination of other factors makes this individual’s risk lower than the African-American attorney.  Option C. 40-year-old Caucasian nurse: While this individual reports high levels of work-related stress, which can be a risk factor for hypertension, they have a healthy BMI, are a vegetarian, and a non-smoker. These factors help offset their risk, making them less likely to develop hypertension compared to the African-American attorney.  Option D. 55-year-old Hispanic teacher: Although this individual smokes occasionally, which is a risk factor for hypertension, they have a healthy BMI and participate in a moderate-intensity exercise program. These factors help reduce their risk, making them less likely to develop hypertension compared to the African-American attorney. 5. 5. Question Category: Pharmacological and Parenteral Therapies A 15-year-old female with a history of depression is rushed to the emergency department after ingesting 15 tablets of maximum-strength acetaminophen 45 minutes ago in a suicide attempt. The patient’s vital signs are stable, but she is visibly anxious and tearful. The healthcare provider has written several orders to manage the situation. Which of the following orders should the nurse prioritize and carry out first?  A. Perform gastric lavage