NCLEX RN COMPRENSIVE TEST BANK WITH 75 QUESTIONS WITH
CORRECT ANSWERS AND RATIONALE
, 1. Question
Category: Health Promotion and Maintenance
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 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. 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
• Instruct the client to remain in bed
• Raise the side rails on the bed
• Have the client empty bladder
Incorrect
Correct order is shown above.
1. 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.
2. Instruct the client to remain in bed. Preoperative medications can cause
drowsiness and lightheadedness which may put the client at risk for injury.
3. 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.
4. Place the call bell within reach. Call bells should always be within the
reach of a client.
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.
• 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).
4. Question
Category: Reduction of Risk Potential
Which individual is at the greatest risk for developing hypertension?
• A. 45-year-old African-American attorney
• B. 60-year-old Asian-American shop owner
• C. 40-year-old Caucasian nurse
• D. 55-year-old Hispanic teacher
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. Question
Category: Pharmacological and Parenteral Therapies
CORRECT ANSWERS AND RATIONALE
, 1. Question
Category: Health Promotion and Maintenance
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 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. 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
• Instruct the client to remain in bed
• Raise the side rails on the bed
• Have the client empty bladder
Incorrect
Correct order is shown above.
1. 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.
2. Instruct the client to remain in bed. Preoperative medications can cause
drowsiness and lightheadedness which may put the client at risk for injury.
3. 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.
4. Place the call bell within reach. Call bells should always be within the
reach of a client.
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.
• 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).
4. Question
Category: Reduction of Risk Potential
Which individual is at the greatest risk for developing hypertension?
• A. 45-year-old African-American attorney
• B. 60-year-old Asian-American shop owner
• C. 40-year-old Caucasian nurse
• D. 55-year-old Hispanic teacher
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. Question
Category: Pharmacological and Parenteral Therapies
