Published - Thu, 23 Feb 2023

NCLEX-RN Exam Questions - Part 58

1. A 1000-mL dose of D5W 12 normal saline is to be infused in 8 hours. The drop factor for the tubing is 60 gtt/min. How many drops per minute should the nurse administer?

A) 75 gtt/min
B) 100 gtt/min
C) 125 gtt/min
D) 150 gtt/min

2. A physicians order reads: 0.25 normal saline at 50 mL/hr until discontinued. The nurse is using a microdrip tubing set. How many drops per minute should the nurse administer?

A) 1 gtt/min
B) 5 gtt/min
C) 50 gtt/min
D) 100 gtt/min

3. A 6-year-old child is attending a pediatric clinic for a routine examination. What should the nurse assess for while conducting a vision screening?

A) Hearing test
B) Gait
C) Strabismus
D) Papilledema

4. An 11-year-old boy has received a partial-thickness burn to both legs. He presents to the emergency room approximately 15 minutes after the accident in excruciating pain with charred clothing to both legs. What is the first nursing action?

A) Apply ice packs to both legs.
B) Begin dÃ©bridement by removing all charred clothing from wound.
C) Apply Silvadene cream (silver sulfadiazine).
D) Immerse both legs in cool water.

5. A burn victim - s immunization history is assessed by the nurse. Which immunization is of priority concern?

A) Oral poliovirus vaccine
B) Inactivated poliovirus vaccine
C) Tetanus toxoid
D) Hepatitis B vaccine

1. Right Answer: C
Explanation: (A) This answer is a miscalculation. (B) This answer is a miscalculation. (C)125 gtt/min. (D) This answer is a miscalculation.

2. Right Answer: C
Explanation: (A) This answer is a miscalculation. (B) This answer is a miscalculation. (C)50 gtt/min. (D) This answer is a miscalculation.

3. Right Answer: C
Explanation: (A) Hearing should be assessed separately. (B) Gait should be assessed separately. Client usually remains in one place for vision screening. Gait is part of neurological assessment. (C) Strabismus is crossing of eyes or outward deviation, which may cause diplopia or ambylopia. It is easily assessed during vision screening. (D) Papilledema is assessed by an ophthalmoscopic examination, which follows vision screening. It is part of neurological assessment.

4. Right Answer: D
Explanation: (A) Ice creates a dramatic temperature change in the tissue, which can cause further thermal injury. (B) Charred clothing should not be removed from wound first.This creates further tissue damage. Dbridement is not the first nursing action. (C) Applying silver sulfadiazine cream first insulates heat in injured tissue and increases potential for infection. (D) Emergency care of a thermal burn is immersing both legs in cool water. Cool water permits gradual temperature change and prevents further thermal damage.

5. Right Answer: C
Explanation: (A) Oral poliovirus vaccine is given to prevent polio. Polio is transmitted by direct contact with an infected person. (B) Inactivated poliovirus vaccine is given to adults and immunosuppressed individuals. Polio is transmitted by direct contact with an infected person. (C) Tetanus toxoid prevents tetanus. Tetanus is transmitted through contaminated wounds. (D) Hepatitis B vaccine prevents hepatitis B infection. Hepatitis B is transmitted through contact with infected blood or body fluids.

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