1. While assessing a one-month-old infant, which of the findings warrants

NCLEX PN-2024

• While assessing a one-month-old infant, which of the findings warrants

further investigation by the nurse? Select all that apply.

• Abdominal respirations

B.Irregular breathing rate C.Inspiratory grunt D.Increased heart rate with crying E.Nasal flaring

• Cyanosis

G.Asymmetric chest movement

• A triage nurse has these four (4) clients arrive in the emergency

department within 15 minutes. Which client should the triage nurse send back to be seen first?B.A teenager who got a singed beard while camping

• While planning care for a toddler, the nurse teaches the parents about the

expected developmental changes for this age. Which statement by the mother shows that she understands the child’s developmental needs?C.“I understand the need to use those new skills.”

• The nurse is preparing to administer an enteral feeding to a client via a

nasogastric feeding tube. The most important action of the nurse is:

• Verify correct placement of the tube

• The nurse is caring for a client with a serum potassium level of 3.5 mEq/L.

The client is placed on a cardiac monitor and receives 40 mEq potassium chloride in 1000 ml of 5% dextrose in water IV. Which of the following EKG patterns indicates to the nurse that the infusions should be discontinued?C.Tall peaked “T” waves

6.A nurse prepares to care for a 4-year-old newly admitted for rhabdomyosarcoma. The nurse should alert the staff to pay more attention to the function of which area of the body?

• All striated muscles

• The nurse anticipates that for a family who practices Chinese medicine the

priority goal would be to:

• Achieve harmony

D.Restore yin and yang

• During an assessment of a client with cardiomyopathy, the nurse finds that

the systolic blood pressure has decreased from 145 to 110 mm Hg and the heart rate has risen from 72 to 96 beats per minute and the client complains

of periodic dizzy spells. The nurse instructs the client to:

C.Force fluids and reassess blood pressure

• The nurse prepares the client for insertion of a pulmonary artery catheter

(Swan-Ganz catheter). The nurse teaches the client that the catheter will

be inserted to provide information about:

D.Left ventricular functioning

10.A nurse enters a client’s room to discover that the client has no pulse or respirations. After calling for help, the first action the nurse should take is: B.Initiate high-quality chest compressions

11.A client is receiving digoxin (Lanoxin) 0.25 mg daily. The health care provider has written a new order to give metoprolol (Lopressor) 25 mg B.I.D. In assessing the client prior to administering the medications, which of the following should the nurse report immediately to the health care provider?

• Blood pressure 94/60 mm Hg

• A nurse is reviewing a patient’s chart and notices that the patient suffers

from Lyme disease. Which of the following microorganisms is related to this condition?A.Borrelia burgdorferi

• A fragile 87-year-old female has recently been admitted to the hospital with

increased confusion and falls over the last two (2) weeks. She is also noted to have a mild left hemiparesis. Which of the following tests is most likely to be performed?

• CT scan

• An 85-year-old male has been losing mobility and gaining weight over the last

two (2) months. The patient also has the heater running in his house 24 hours a day, even on warm days. Which of the following tests is most likely to be

performed?C.Thyroid function tests

• A 20-year-old female attending college is found unconscious in her dorm room.

She has a fever and a noticeable rash. She has just been admitted to the hospital. Which of the following tests is most likely to be performed first?C.Blood cultures

• What would the nurse expect to see while assessing the growth of children

during their school age years?D.Yearly weight gain of about 5.5 pounds per year

• At a community health fair, the blood pressure of a 62-year-old client is

160/96 mmHg. The client states “My blood pressure is usually much lower.”

The nurse should tell the client to:

• Go get a blood pressure check within the next 15 minutes

• The hospital has sounded the call for a disaster drill on the evening shift.

Which of these clients would the nurse put first on the list to be discharged in order to make a room available for a new admission?

• A middle-aged client with a history of being ventilator dependent for over

seven (7) years and admitted with bacterial pneumonia five days ago.

• A 25-year-old male client has been newly diagnosed with hypothyroidism and

will take levothyroxine (Synthroid) 50 mcg/day by mouth. As part of the

teaching plan, the nurse emphasizes that this medication:

• Should be taken in the morning

• A 3-year-old child was brought to the pediatric clinic after the sudden onset of

findings that include irritability, thick muffled voice, croaking on inspiration, hot to touch, sit leaning forward, tongue protruding, drooling and suprasternal retractions. What should the nurse do first?D.Notify the healthcare provider of the child’s status

• In children suspected to have a diagnosis of diabetes, which one of the

following complaints would be most likely to prompt parents to take their school-age child for evaluation?C.Bedwetting

• A client comes to the clinic for treatment of recurrent pelvic inflammatory

disease. The nurse recognizes that this condition most frequently follows which type of infection?B.Chlamydia

• A registered nurse who usually works in a spinal rehabilitation unit is floated to

the emergency department. Which of these clients should the charge nurse assign to this RN?C.An adolescent who has been on pain medications terminal cancer with an initial assessment finding pupils and a relaxed respiratory rate of 11,

• When teaching a client with coronary artery disease about nutrition, the nurse

should emphasize:

C.Avoiding very heavy meals

• To assist an adult client to sleep better the nurse recommends which of the following? (Select all

that apply.)

• Drinking a glass of wine just before retiring to bed
• Eating a large meal 1 hour before bedtime
• Consuming a small glass of warm milk at bedtime

• The nurse recognizes that a client is experiencing insomnia when the client reports (select all that

apply):

• Extended time to fall asleep
• Difficulty staying asleep
• Feeling tired after a night’s sleep

.

• The nurse teaches the mother of a newborn that in order to prevent sudden infant death syndrome

(SIDS) the best position to place the baby after nursing is (select all that apply):

• Side-lying
• Supine

• A client has a diagnosis of primary insomnia. Before assessing this client, the nurse recalls the

numerous causes of this disorder. Select all that apply:

• Chronic stress
• Excessive caffeine
• Environmental noise

29. Select all that apply to the use of barbiturates in treating insomnia:

• Barbiturates deprive people of REM sleep
• When the barbiturates are discontinued, the REM sleep increases.