a physician has ordered that a client must be placed in a high fowlers position how does the nurse position this client a physician has ordered that a client must be placed in a high fowlers position how does the nurse position this client
Logo

Nursing Elites

NCLEX NCLEX-RN

Safe and Effective Care Environment NCLEX RN Questions

1. 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: The client is sitting with the backrest at a 90-degree angle

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.

2. A child is seen in the emergency department for scarlet fever. Which of the following descriptions of scarlet fever is not correct?

Correct answer: Petechiae occur on the soft palate.

Rationale: Petechiae on the soft palate are not a typical finding in scarlet fever. Scarlet fever is caused by group A Streptococcus bacteria, often presenting with a strawberry tongue, red and swollen pharynx, and a sandpaper-like rash. The presence of petechiae on the soft palate is more commonly associated with conditions like rubella rather than scarlet fever. Therefore, this description is not correct in the context of scarlet fever.

3. When taking Mr. D's blood pressure, the first sound you hear is at 162, and the second sound you hear is at 86. You should document and report that the blood pressure is _____________.

Correct answer: 162/86

Rationale: You should document and report that the blood pressure measurement for Mr. D is 162/86. The first sound heard corresponds to the systolic reading (top number), and the second sound corresponds to the diastolic reading (bottom number). Blood pressure readings are not irregular; irregularities are typically associated with pulses. The blood pressure recorded is not normal for individuals of all ages; it is considered high.

4. A woman has died as a result of a motor vehicle accident. She is listed as an organ donor, and her family is considering whether to comply with her wishes. Which of the following is true?

Correct answer: Physicians can choose to go against the deceased's wishes if the family decides that organ donation is not an acceptable choice.

Rationale: In cases where a deceased person is listed as an organ donor, the family may have the final say on whether to proceed with organ donation, even if the individual had expressed their wish to donate. Physicians may prioritize the emotional well-being of the family over the wishes of the deceased, especially if organ donation could cause additional distress or trauma to the grieving family members. Therefore, it is possible for physicians to respect the family's decision not to proceed with organ donation, even if the deceased had previously expressed the desire to donate. This decision-making process underscores the importance of considering and respecting the perspectives and emotions of both the deceased individual and their surviving family members in organ donation scenarios.

5. A client with untreatable metastasized cancer tells the nurse, 'I think they made a mistake. I don't think I have cancer. I feel too good to be dying.' Which stage of grief is the client experiencing?

Correct answer: Denial

Rationale: The client is experiencing the stage of denial. This is evident as the client is having difficulty accepting the reality of their diagnosis and denies the presence of cancer despite the evidence. During the anger stage, the individual expresses anger about their situation, questioning why it is happening to them. Bargaining involves attempting to negotiate for more time or a different outcome, acknowledging the reality of death but trying to delay it. Acceptance, on the other hand, is characterized by coming to terms with the inevitability of death and preparing for it peacefully. Therefore, in this scenario, the client's disbelief and refusal to accept the diagnosis align with the denial stage of grief.

Similar Questions

The nurse is caring for a Native American patient who has traditional beliefs about health and illness. Which action by the nurse is most appropriate?
Which term describes what an adolescent client is experiencing when she says to the nurse who has been caring for her, 'You're just like my mother; I hate you'?
A complication of osteoporosis is _______________?
A client is having difficulties reading an educational pamphlet. He cannot find his glasses. In order to read the words, he must hold the pamphlet at arm's length, which allows him to read the information. Which vision deficit does this client most likely suffer from?
A nurse is preparing to irrigate a client's indwelling catheter through a closed, intermittent system. Which of the following steps must the nurse take as part of this process?

Access More Features

NCLEX Basic

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access @ $69.99

NCLEX Basic

  • 5,000 Questions and answers
  • Comprehensive NCLEX Coverage
  • 90 days access @ $69.99