NCLEX-RN Practice Quiz Test Bank #2 (75
Questions)
1. 1. Question
While assessing a one-month-old infant, which of the 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
Incorrect
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
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
Instruct the client to remain in bed
Have the client empty bladder
Raise the side rails on the bed
Incorrect
Correct order is shown above.
5. 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.
6. Instruct the client to remain in bed. Preoperative
medications can cause drowsiness and lightheadedness which
may put the client at risk for injury.
7. 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.
, 8. Place the call bell within reach. Call bells should always be
within the reach of a client.
3. 3. Question
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)
Incorrect
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).
4. 4. Question
Which individual is at the greatest risk for developing hypertension?
o A. 45-year-old African-American attorney
o B. 60-year-old Asian-American shop owner
o C. 40-year-old Caucasian nurse
o D. 55-year-old Hispanic teacher
Incorrect
Correct Answer: A: 45-year-old African American attorney
Option A: African-Americans develop high blood pressure at
younger ages than other groups in the US. Researchers have
uncovered that African-Americans respond differently to
hypertensive drugs than other groups of people. They are also
found out to be more sensitive to salt, which increases the risk of
developing hypertension.
, Option B: The incidence of hypertension in Asian-Americans
does not appear to be significantly higher than the general
population, according to limited US data.
Option C: The racial disparity in hypertension and hypertension-
related outcomes has been recognized for decades with African-
Americans with greater risks than Caucasians.
Option D: Hypertension prevalence rates in Hispanics may vary
by gender and country of origin. Hispanic Americans overall have
relatively low levels of hypertension, despite elevated levels of
diabetes and obesity.
5. 5. Question
A 15-year-old female who ingested 15 tablets of maximum strength
acetaminophen 45 minutes ago is rushed to the emergency
department. Which of these orders should the nurse do first?
A. Gastric lavage
B. Administer acetylcysteine (Mucomyst) orally
C. Start an IV Dextrose 5% with 0.33% normal saline to keep the
vein open
D. Have the patient drink activated charcoal mixed with water
Incorrect
Correct Answer: A. Gastric lavage
Option A: Acetaminophen overdose is extremely toxic to the
liver causing hepatotoxicity. Early symptoms of hepatic damage
include nausea, vomiting, abdominal pain, and diarrhea. If not
treated immediately, hepatic necrosis occurs and may lead to
death. Removing as much of the drug as possible is the first step
in treatment for acetaminophen overdose, this is best done
through gastric lavage. Gastric lavage (irrigation) and aspiration
consist of flushing the stomach with fluids and then aspirating the
fluid back out. This procedure is done in life-threatening cases
such as acetaminophen toxicity and only if less than one (1) hour
has occurred after ingestion.
Option B: The oral formulation of acetylcysteine is the drug of
choice for the treatment of acetaminophen overdose but should
be done after GI decontamination with activated charcoal. Liver
damage is minimized by giving acetylcysteine (Mucomyst), the
Questions)
1. 1. Question
While assessing a one-month-old infant, which of the 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
Incorrect
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
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
Instruct the client to remain in bed
Have the client empty bladder
Raise the side rails on the bed
Incorrect
Correct order is shown above.
5. 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.
6. Instruct the client to remain in bed. Preoperative
medications can cause drowsiness and lightheadedness which
may put the client at risk for injury.
7. 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.
, 8. Place the call bell within reach. Call bells should always be
within the reach of a client.
3. 3. Question
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)
Incorrect
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).
4. 4. Question
Which individual is at the greatest risk for developing hypertension?
o A. 45-year-old African-American attorney
o B. 60-year-old Asian-American shop owner
o C. 40-year-old Caucasian nurse
o D. 55-year-old Hispanic teacher
Incorrect
Correct Answer: A: 45-year-old African American attorney
Option A: African-Americans develop high blood pressure at
younger ages than other groups in the US. Researchers have
uncovered that African-Americans respond differently to
hypertensive drugs than other groups of people. They are also
found out to be more sensitive to salt, which increases the risk of
developing hypertension.
, Option B: The incidence of hypertension in Asian-Americans
does not appear to be significantly higher than the general
population, according to limited US data.
Option C: The racial disparity in hypertension and hypertension-
related outcomes has been recognized for decades with African-
Americans with greater risks than Caucasians.
Option D: Hypertension prevalence rates in Hispanics may vary
by gender and country of origin. Hispanic Americans overall have
relatively low levels of hypertension, despite elevated levels of
diabetes and obesity.
5. 5. Question
A 15-year-old female who ingested 15 tablets of maximum strength
acetaminophen 45 minutes ago is rushed to the emergency
department. Which of these orders should the nurse do first?
A. Gastric lavage
B. Administer acetylcysteine (Mucomyst) orally
C. Start an IV Dextrose 5% with 0.33% normal saline to keep the
vein open
D. Have the patient drink activated charcoal mixed with water
Incorrect
Correct Answer: A. Gastric lavage
Option A: Acetaminophen overdose is extremely toxic to the
liver causing hepatotoxicity. Early symptoms of hepatic damage
include nausea, vomiting, abdominal pain, and diarrhea. If not
treated immediately, hepatic necrosis occurs and may lead to
death. Removing as much of the drug as possible is the first step
in treatment for acetaminophen overdose, this is best done
through gastric lavage. Gastric lavage (irrigation) and aspiration
consist of flushing the stomach with fluids and then aspirating the
fluid back out. This procedure is done in life-threatening cases
such as acetaminophen toxicity and only if less than one (1) hour
has occurred after ingestion.
Option B: The oral formulation of acetylcysteine is the drug of
choice for the treatment of acetaminophen overdose but should
be done after GI decontamination with activated charcoal. Liver
damage is minimized by giving acetylcysteine (Mucomyst), the
