a physician may assess turgor when

NCLEX-RN

NCLEX RN Actual Exam Test Bank

1. When is a physician likely to assess turgor?

A. When iron deficiency is suspected.
B. When heart and lung issues are suspected.
C. When dehydration is suspected.
D. None of the above.

Correct answer: C

Rationale: Skin turgor is assessed when dehydration is suspected. To evaluate skin turgor, a physician pinches the skin and observes how quickly it returns to its normal position. If the skin stays folded for an extended period, it indicates dehydration. Assessing turgor helps determine a patient's hydration status. Choice A is incorrect because skin turgor is not used to assess iron deficiency. Choice B is incorrect as turgor is not related to heart and lung issues, but rather hydration status. Choice D is incorrect as turgor assessment is relevant when dehydration is suspected.

2. During a class on the aspects of culture, the instructor shares that culture has four basic characteristics. Which statement correctly reflects one of the characteristics of culture?

A. Static and unchanging
B. Members sharing similar physical characteristics
C. Members sharing a common geographic origin and religion
D. Adapted to specific conditions related to environmental and technical factors

Correct answer: D

Rationale: Culture has four basic characteristics, one of which is that it is adapted to specific conditions related to environmental and technical factors and to the availability of natural resources. The other three characteristics are: (1) learned from birth through the processes of language acquisition and socialization; (2) shared by all members of the cultural group; and (3) dynamic and ever-changing. Culture is not static and unchanging but is dynamic and ever-changing. Members of a culture do not necessarily share similar physical characteristics; that refers to race. Similarly, members of a culture do not necessarily share a common geographic origin and religion; that refers to ethnicity.

3. The Rule of Nines is used to:

A. determine the amount of the body surface that has been burned
B. assess the level of oxygen saturation in a body that has been burned.
C. determine the level of tissue damage that has occurred in a burn.
D. None of the above.

Correct answer: A

Rationale: The Rule of Nines is used to assess the amount of body surface that has been burned. Most body areas are divided out based on 9%, with the exception of the genitalia, which is only 1%.

4. When measuring the vital signs of a 6-month-old infant, which action by the nurse is correct?

A. Respirations are measured first, followed by pulse and temperature.
B. Vital signs should be measured as frequently as in an adult.
C. Procedures are explained to the parent, and the infant is encouraged to handle the equipment.
D. The nurse should first measure the infant's vital signs before performing a physical examination.

Correct answer: A

Rationale: When assessing vital signs in a 6-month-old infant, the correct order is to measure respirations first, followed by pulse and temperature. This sequence is important to avoid potential alterations in respiratory and pulse rates caused by factors like crying or discomfort. Measuring the temperature first, especially rectally, may lead to an increase in respiratory and pulse rates, which can skew the results. It is crucial to follow this specific order to obtain accurate baseline values. Therefore, option A is the correct choice. Option B is incorrect as the frequency of measuring vital signs in infants differs based on individual needs rather than being consistently more frequent than in adults. Option C is not directly related to the correct sequence for measuring vital signs in infants. Option D is incorrect because the physical examination typically follows the assessment of vital signs in clinical practice.

5. The nurse receives change-of-shift report on the following four patients. Which patient should the nurse assess first?

A. A 23-year-old patient with cystic fibrosis who has pulmonary function testing scheduled
B. A 46-year-old patient on bed rest who is complaining of sudden onset of shortness of breath
C. A 77-year-old patient with tuberculosis (TB) who has four antitubercular medications due in 15 minutes
D. A 35-year-old patient who was admitted the previous day with pneumonia and has a temperature of 100.2 F (37.8 C)

Correct answer: B

Rationale: The correct answer is the 46-year-old patient on bed rest who is complaining of sudden onset of shortness of breath. Patients on bed rest who are immobile are at high risk for deep vein thrombosis (DVT). Sudden onset of shortness of breath in a patient with a DVT suggests a pulmonary embolism, which requires immediate assessment and action such as oxygen administration to maintain adequate oxygenation. The other patients should also be assessed as soon as possible, but they do not present with an immediate life-threatening condition that requires urgent intervention like the patient experiencing sudden shortness of breath.