Question

The nurse is taking care of a 7-year-old female patient admitted for cellulitis of the right arm.

Answer 1

Correct Answers:

Fill out an event report and notify the provider.
Obtain a set of vital signs and assess neurological function.

Rationale :

⚠️An overdose of cefazolin increases the risk of toxicity, so immediate evaluation is essential.

🩺Obtaining vital signs and assessing neurological function alerts the nurse to early signs of adverse reactions.

📞Notifying the provider ensures timely orders for any necessary interventions or monitoring.

📝Completing an event report documents the error for quality improvement and system safety.

📌Core Message

Immediately assess for toxicity and report the error to ensure patient safety and regulatory compliance.

Answer 2

Correct Answers:

Requiring that the client empty his or her bladder prior to auscultating the abdomen

Rationale :

🛁Emptying the bladder removes bladder distention that can dampen bowel sounds.

🎧An empty bladder enhances acoustic transmission, allowing clearer auscultation.

🔍A full bladder may produce false dullness, leading to misinterpretation of bowel motility.

📋Standardizing the abdominal environment by voiding ensures a consistent assessment.

📌Core Message

An emptied bladder prevents interference and allows clear bowel sound assessment.

Answer 3

Correct Answers:

A 27-year-old client with unstable hyperthyroidism who has a heart rate of 110 beats per minute

Rationale :

🎚️This client’s hemodynamic stability with only mild tachycardia minimizes immediate risk of deterioration.

🎂As a young adult, they have greater physiological reserve to tolerate fluctuations.

📋The absence of recent surgical interventions reduces the likelihood of postoperative complications requiring close surveillance.

👀Being fully oriented and cooperative means they need less intensive monitoring than the others.

📌Core Message

The young adult with unstable hyperthyroidism and mild tachycardia requires less constant monitoring than the other clients.

Answer 4

Correct Answers:

Secure the line per policy and cover the line with gauze to disguise it.

Rationale :

🛡️Securing the central line per policy prevents catheter dislodgement or movement.

🩹Using an appropriate dressing ensures the insertion site remains sterile and visible for monitoring.

💉Proper stabilization of the line reduces the risk of infection and mechanical complications.

📈Standardizing line care promotes consistent and safe practice.

📌Core Message

Policy-aligned stabilization and sterile dressing maintain central line safety.

Answer 5

Correct Answers:

Anticipate changing to a lactose-free formula.
Change the feeding apparatus every 24 hours.
Slow the administration rate.
Use a diluted formula, gradually increasing the volume and concentration.

Rationale :

🥛Anticipating a switch to a lactose-free formula addresses potential lactose intolerance, a common cause of diarrhea and cramping.

🧪Changing the feeding apparatus every 24 hours prevents bacterial overgrowth that can exacerbate gastrointestinal symptoms.

🐢Slowing the administration rate reduces the osmotic load on the intestines, thereby minimizing abdominal distention and discomfort.

💧Using a diluted formula with gradual increases in volume and concentration promotes intestinal adaptation and prevents feeding intolerance.

📌Core Message

Adjusting formula type, equipment, administration rate, and concentration enhances tube feeding tolerance.

Answer 6

Correct Answers:

A client who sustained a leg fracture during a sporting event

Rationale :

🦴A client with an isolated leg fracture is at lower acuity and requires basic orthopedic care.

📋Clients with polypharmacy or septicemia demand complex medication and monitoring skills.

🚑An alcoholic client detoxing needs close surveillance for withdrawal complications.

🔰New nurses benefit from caring for straightforward cases that build confidence and skill.

📌Core Message

Assign low-acuity, straightforward cases to new nurses to foster competence.

Answer 7

Correct Answers:

Carotid

Rationale :

👂The carotid pulse provides the most reliable site during emergent assessments in unconscious adults.

✋Brachial and radial pulses may be weak or difficult to palpate in an unresponsive patient.

🦵Popliteal pulses are not routinely used for rapid primary surveys.

📈Palpating carotid ensures rapid evaluation of central perfusion.

📌Core Message

Use the carotid pulse for rapid, reliable assessment in unconscious adults.

Answer 8

Correct Answers:

Administer the medication as ordered.

Rationale :

📊The dose of 50 mg falls within the safe range of 10–15 mg/kg for a 4.5 kg infant.

🩺Administering the correct weight-based dose maintains therapeutic effectiveness.

⚖️Deviating from a safe, recommended range can result in under or overdosing with adverse effects.

✔️Following established pediatric dosing guidelines ensures patient safety.

📌Core Message

Weight-based dosing within 10–15 mg/kg ensures safe and effective acetaminophen use.

Answer 9

Correct Answers

Administer flu shot IM [ Not Indicated ]
Administer IV ampicillin [ Indicated ]
Administer ibuprofen q6 [ Not Indicated ]
Administer rectal diazepam [ Not Indicated ]
Administer acetaminophen q6 [ Indicated ]

Rationale :

🍼Vaccines like the influenza vaccine are recommended beginning at 6 months, so a flu shot is contraindicated in a 21-day-old.

💉Empiric IV ampicillin is indicated for suspected neonatal sepsis, providing necessary broad-spectrum coverage.

🚫Ibuprofen is not approved for infants under 6 months, making it inappropriate for this neonate’s fever.

💤Rectal diazepam is reserved for seizure emergencies, and no seizure activity was documented.

🌡️Acetaminophen q6 h is an approved antipyretic at this infant’s weight and age for fever management.

📌Core Message

Medication choices for neonates must follow age-appropriate guidelines and address specific clinical indications.

Answer 10

Correct Answers:

The line is flushed for patency daily.
Placement is done under a sterile procedure.
The dressing is changed every 7 days.

Rationale :

🧪Flushing the line daily maintains patency and prevents clot formation.

🩺Placement under a sterile procedure minimizes infection risk during insertion.

📆Changing a transparent dressing every 7 days aligns with best practices.

❌Neither the line’s termination in the stomach nor absence of infection risk is accurate.

📌Core Message

Daily flushing, sterile placement, and weekly dressing changes ensure central line safety.

BP	104/76 mmHg
HR	118
RR	24
T	98.8°F (37.1°C)
SpO₂	100% on room air
Pain	4/10
Weight	62 lbs

HR	145
RR	45
T (rectal)	101.4°F (38.6°C)
SpO₂	97% on room air

HR	145
RR	45
T (rectal)	101.4°F (38.6°C)
SpO₂	97% on room air

Medication	Indicated	Not Indicated
Administer flu shot IM
Administer IV ampicillin
Administer ibuprofen q6
Administer rectal diazepam
Administer acetaminophen q6

NCLEX-RN Practice Exam-4

No.

1 :
The nurse is taking care of a 7-year-old female patient admitted for cellulitis of the right arm.

Answer Options

2 :
A client seeks medical attention in the emergency department after developing acute abdominal pain two days prior. Which of the following actions by the nurse helps ensure accurate auscultation of the client's bowel sounds?

3 :
A nurse is assigning beds to four new clients being admitted to the cardiac telemetry floor. Which of the following clients would most appropriately be assigned to the bed at the end of the hall, away from the nurses' station?

4 :
A nurse is caring for a client with confusion secondary to a urinary tract infection. The client has just had a central intravenous (IV) line placed by the physician for antibiotic administration. Following the procedure, it is important for the nurse to complete which of the following?

5 :
A client being treated in a medical-surgical unit is receiving tube feedings. Over the past two days, the client has developed diarrhea, cramps, and abdominal distention. Which of the following interventions would be most appropriate for the nurse to complete? Select all that apply.

6 :
A nurse manager is scheduling nursing shifts for the next week. Which client would be best placed with a new nurse?

7 : A nurse finds an adult client on the floor, unconscious in the bathroom. The nurse completes a rapid nursing assessment, which will include palpation of which of the following pulse sites?

8 :
The nurse in the emergency department is caring for a 21-day-old infant who weighs 4.5 kg.

Answer Options

9 :
The nurse in the emergency department is caring for a 21-day-old infant who weighs 4.5.

Correct Answers

NCLEX-RN Practice Exam-4

No.

1 : The nurse is taking care of a 7-year-old female patient admitted for cellulitis of the right arm.

Answer Options

2 : A client seeks medical attention in the emergency department after developing acute abdominal pain two days prior. Which of the following actions by the nurse helps ensure accurate auscultation of the client's bowel sounds?

3 : A nurse is assigning beds to four new clients being admitted to the cardiac telemetry floor. Which of the following clients would most appropriately be assigned to the bed at the end of the hall, away from the nurses' station?

4 : A nurse is caring for a client with confusion secondary to a urinary tract infection. The client has just had a central intravenous (IV) line placed by the physician for antibiotic administration. Following the procedure, it is important for the nurse to complete which of the following?

5 : ﻿A client being treated in a medical-surgical unit is receiving tube feedings. Over the past two days, the client has developed diarrhea, cramps, and abdominal distention. Which of the following interventions would be most appropriate for the nurse to complete? Select all that apply.

6 : A nurse manager is scheduling nursing shifts for the next week. Which client would be best placed with a new nurse?

7 : A nurse finds an adult client on the floor, unconscious in the bathroom. The nurse completes a rapid nursing assessment, which will include palpation of which of the following pulse sites?

8 : The nurse in the emergency department is caring for a 21-day-old infant who weighs 4.5 kg.

Answer Options

9 : The nurse in the emergency department is caring for a 21-day-old infant who weighs 4.5.

Correct Answers

1 :
The nurse is taking care of a 7-year-old female patient admitted for cellulitis of the right arm.

2 :
A client seeks medical attention in the emergency department after developing acute abdominal pain two days prior. Which of the following actions by the nurse helps ensure accurate auscultation of the client's bowel sounds?

3 :
A nurse is assigning beds to four new clients being admitted to the cardiac telemetry floor. Which of the following clients would most appropriately be assigned to the bed at the end of the hall, away from the nurses' station?

4 :
A nurse is caring for a client with confusion secondary to a urinary tract infection. The client has just had a central intravenous (IV) line placed by the physician for antibiotic administration. Following the procedure, it is important for the nurse to complete which of the following?

5 :
A client being treated in a medical-surgical unit is receiving tube feedings. Over the past two days, the client has developed diarrhea, cramps, and abdominal distention. Which of the following interventions would be most appropriate for the nurse to complete? Select all that apply.

6 :
A nurse manager is scheduling nursing shifts for the next week. Which client would be best placed with a new nurse?

8 :
The nurse in the emergency department is caring for a 21-day-old infant who weighs 4.5 kg.

9 :
The nurse in the emergency department is caring for a 21-day-old infant who weighs 4.5.