NCLEX RN
Real Authentic Exam
(Testbank)
Questions with verified correct detailed
answers Latest Accurate Version 2025-
2026
100% Pass Guarantee
(Comprehensive Study Guide & Practice)
, NCLEX RN Real Authentic Exam (Testbank)
Questions with verified correct detailed answers
Latest Accurate Version 2025-2026 100% Pass
Guarantee (Comprehensive Study Guide & Practice)
While assessing a one-month-old infant, which of the findings
warrants further investigation by the nurse? Select all that apply.
A. Abdominal respirations
B. Irregular breathing rate
C. Inspiratory grunt
D. Increased heart rate with crying
E. Nasal flaring
F. Cyanosis
G. Asymmetric chest movement --- correct precise answer ---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.
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.
a. Have the client empty bladder
b. Instruct the client to remain in bed
c. Raise the side rails on the bed
d. place the call bell within reach --- correct precise answer ---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.
Instruct the client to remain in bed. Preoperative medications can
cause drowsiness and lightheadedness which may put the client at
risk for injury. 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. Place the call bell
within reach. Call bells should always be within the reach of a client.
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
Real Authentic Exam
(Testbank)
Questions with verified correct detailed
answers Latest Accurate Version 2025-
2026
100% Pass Guarantee
(Comprehensive Study Guide & Practice)
, NCLEX RN Real Authentic Exam (Testbank)
Questions with verified correct detailed answers
Latest Accurate Version 2025-2026 100% Pass
Guarantee (Comprehensive Study Guide & Practice)
While assessing a one-month-old infant, which of the findings
warrants further investigation by the nurse? Select all that apply.
A. Abdominal respirations
B. Irregular breathing rate
C. Inspiratory grunt
D. Increased heart rate with crying
E. Nasal flaring
F. Cyanosis
G. Asymmetric chest movement --- correct precise answer ---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.
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.
a. Have the client empty bladder
b. Instruct the client to remain in bed
c. Raise the side rails on the bed
d. place the call bell within reach --- correct precise answer ---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.
Instruct the client to remain in bed. Preoperative medications can
cause drowsiness and lightheadedness which may put the client at
risk for injury. 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. Place the call bell
within reach. Call bells should always be within the reach of a client.
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
