NCLEX-RN EXAM PACK SET 2 75 QUESTIONS & ANSWERS WITH EXPLANATIONS {LATEST UPDATED 2024}

Question 1 A nurse was instructed by a physician to give clarithromycin (Biaxin) for a child whose BSA is 0.55 m2. The usual adult dose is 500 mg. Biaxin is available in an oral suspension. The 100ml bottle is labeled 50 mg/ml. How many ml would the nurse give per dose? Fill in the blanks. Record your answer using one decimal place. Answer: (3.2) mL. Correct answer: 3.2 mL. Formula: BS A Formula: BSA Formula: Rationale:  Use the BSA formula first then the standard formula as shown above.  To get the child‟s dose, multiply 0.55m2(child‟s BSA) to 500 mg (usual adult dose) to get 275.  Divide 275 with 1.7 m2to get 161.76 mg.  Use the standard formula above.  Divide 161.76 mg (desired pedia dose) with 50 mg (drug on hand) and multiply by 1 ml (vehicle) to get 3.2 ml. Question 2 A 28-year-old male has been found wandering around in a confusing pattern. The male is sweaty and pale. Which of the following tests is most likely to be performed first? A. Blood sugar check B. CT scan C. Blood cultures D. Arterial blood gases Correct Answer: A. Blood sugar check With a history of diabetes, the first response should be to check blood sugar levels.  Option B: Performing a CT scan at this stage of assessment is unnecessary. A computerized tomography (CT) scan combines a series of X-ray images taken from different angles around the body and uses computer processing to create cross- sectional images (slices) of the bones, blood vessels, and soft tissues inside the body. CT scan images provide more detailed information than plain X-rays do.  Option C: A blood culture test helps the doctor figure out if the client has a kind of infection that is in the bloodstream and can affect the entire body. Doctors call this a systemic infection. The test checks a sample of the blood for bacteria or yeast that might be causing the infection.  Option D: An arterial blood gas (ABG) test measures oxygen and carbon dioxide levels in the blood. It also measures the body‟s acid-base (pH) level, which is usually in balance when healthy. Question 3 A mother is inquiring about her child‟s ability to potty train. Which of the following factors is the most important aspect of toilet training? A. The age of the child B. The child's ability to understand instruction C. The overall mental and physical abilities of the child D. Frequent attempts with positive reinforcement Question 4 A parent calls the pediatric clinic and is frantic about the bottle of cleaning fluid her child drank for 20 minutes. Which of the following is the most important instruction the nurse can give the parent? A. This too shall pass B. Take the child immediately to the ER C. Contact the Poison Control Center quickly D. Give the child syrup of ipecac Correct Answer: C. Contact the Poison Control Center quickly. The poison control center will have an exact plan of action for this child.  Option A: Ingestion of a chemical is an emergency and should not be delayed.  Option B: Taking the client to the ER may be correct, however, they will still have to contact the Poison Control Center.  Option D: It should not be given to someone who swallowed chemicals that cause burns on contact or medicines that can cause seizures very quickly. It can be dangerous to people with some types of medical problems. When such poisoning victims got Ipecac anyway, they developed serious complications or even died. Question 5 A nurse is administering a shot of Vitamin K to a 30 day-old infant. Which of the following target areas is the most appropriate? A. Gluteus maximus B. Gluteus minimus C. Vastus lateralis D. Vastus medialis Correct Answer: C. Vastus lateralis Medications are injected into the bulkiest part of the vastus lateralis thigh muscle, which is the junction of the upper and middle thirds of this muscle.  Option A: Intramuscular injections given at the dorsogluteal and ventrogluteal sites are intended for the gluteus maximus and gluteus medius muscles, respectively. However, little research has confirmed the reliability of these sites for the presence and thickness of the target and other muscles, and subcutaneous fat.  Option B: Never give an IM injection in the gluteal muscles to avoid the risk of sciatica nerve damage.  Option D: The vastus medialis muscle is a part of the quadriceps muscle group, located on the front of the thigh. Question 6 A nurse has just started her rounds delivering medication. A new patient on her rounds is a 4year-old boy who is non-verbal. This child does not have any identification on. What should the nurse do? A. Contact the provider B. Ask the child to write their name on paper C. Ask a coworker about the identification of the child D. Ask the father who is in the room the child’s name Correct Answer: D. Ask the father who is in the room the child’s name. In this case, you can determine the name of the child by the father’s statement. You should not withhold the medication from the child after identification.  Option A: Contacting the provider is unnecessary and may take time. A pediatric patient must have folks with them inside the room, so asking the child’s folks would be the most appropriate intervention.  Option B: The child may have not yet developed his writing abilities. Some children are able to write their names at age 4, but some typically developing children still aren’t ready until well into age.  Option C: Asking a coworker would be inappropriate and against the patient’s confidentiality. Question 7 A patient is admitted to the hospital with a diagnosis of primary hyperparathyroidism. A nurse checking the patient‟s lab results would expect which of the following changes in laboratory findings? A. Elevated serum calcium B. Low serum parathyroid hormone (PTH) C. Elevated serum vitamin D D. Low urine calcium