the nurse observes a student who is listening to a patients lungs who is having no problems with breathing which action by the student indicates a ne
Logo

Nursing Elites

NCLEX-RN

Safe and Effective Care Environment NCLEX RN Questions

1. The student observes a patient with no breathing problems. Which action by the student indicates a need to review respiratory assessment skills?

Correct answer: C

Rationale: The correct answer is C. Listening only during inspiration instead of both inspiration and expiration indicates a need for a review of respiratory assessment skills. During chest auscultation, it is essential to listen to at least one cycle of inspiration and expiration at each placement of the stethoscope. Instructing the patient to breathe slowly and a little deeper than normal through the mouth is a correct practice during auscultation. The correct sequence for lung auscultation is from the apices to the bases, comparing breath sounds bilaterally, avoiding bony areas. It is crucial to place the stethoscope over lung tissue rather than bony prominences to accurately assess lung sounds.

2. Which of the following is an example of physical abuse?

Correct answer: A

Rationale: The correct answer is 'A slap to the person's hand.' Slapping, hitting, and punching are clear examples of physical abuse. Physical abuse involves actions that can cause physical harm or injury to a person. Choice B, 'Threatening the person,' falls under the category of emotional or psychological abuse, where threats can cause fear and emotional distress but do not involve physical harm. Choice C, 'Ignoring and isolating a person,' is a form of neglect or emotional abuse, not physical abuse. Choice D, 'Leaving a patient soiled for hours,' is an example of neglect or lack of proper care, which is also not classified as physical abuse.

3. Digestion, elimination, and ___________ are the three functions of the digestive system.

Correct answer: C

Rationale: The correct answer is 'absorption.' The three main functions of the digestive system are digestion, absorption, and elimination. Absorption refers to the process of absorbing nutrients and other substances from the digested food into the bloodstream. Choices A, B, and D are incorrect: Constriction is not a primary function of the digestive system, relaxation is not a distinct function in this context, and peristalsis is a muscular movement that aids in digestion but is not one of the three main functions of the digestive system.

4. When assessing the pulse of a 6-year-old patient, the nurse notices that the heart rate varies with the respiratory cycle, speeding up at the peak of inspiration and slowing to normal with expiration. What action would the nurse take next?

Correct answer: B

Rationale: The correct action for the nurse to take next is to record this finding as normal. Sinus dysrhythmia, characterized by heart rate variation with the respiratory cycle, is commonly found in children and young adults. The heart rate speeds up at the peak of inspiration and slows to normal with expiration. This phenomenon is a normal variant and does not require any intervention. There is no need to notify the physician as this finding is within the expected range for this age group. Checking the child's blood pressure for variations with respiration or documenting the child as having bradycardia would not be appropriate in this case, as sinus dysrhythmia is a normal physiological response.

5. A physician has ordered that a client must be placed in a high Fowler's position. How does the nurse position this client?

Correct answer: D

Rationale: A high Fowler's position is a modification of the semi-Fowler's position, in which the client is seated with arms resting at the sides or in the lap. The high Fowler's position requires that the client's head and upper chest are elevated, and the backrest is at a 90-degree angle. This position supports breathing and appropriate chest wall movement, making it easier for the client to breathe. Choices A, B, and C are incorrect because a high Fowler's position involves the client being in a sitting position with the backrest at a 90-degree angle, not being face-down, lying with the head lower than the feet, or lying on the back with knees drawn up towards the chest.

Similar Questions

Before allowing the client's infant granddaughter to visit before the client's scheduled heart transplant, the nurse decides it would be beneficial to collaborate with which of the following? Select all that apply.
An adult's blood pressure reads 40/20. You place the patient in a Trendelenberg position before rechecking the blood pressure. What actions will you take to position the patient correctly?
For a healthcare worker under normal conditions with unsoiled hands, effective hand hygiene between patients requires which of the following?
Where is the duodenum located in the digestive system?
When measuring the vital signs of a 6-month-old infant, which action by the nurse is correct?

Access More Features

NCLEX RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access

NCLEX RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access

Other Courses