over a patients lifespan the pulse rate

NCLEX-RN

NCLEX RN Actual Exam Test Bank

1. Over a patient's lifespan, how does the pulse rate change?

A. starts out fast and decreases as the patient ages.
B. starts out slower and increases as the patient ages.
C. varies from slow to fast throughout the lifespan.
D. stays consistent from birth to death.

Correct answer: A

Rationale: The correct answer is that the pulse rate starts out fast and decreases as the patient ages. In infants, the normal pulse rate is around 140 beats per minute, which then falls to an average of 80 beats per minute in adults. As individuals age, their pulse rate tends to decrease due to changes in cardiovascular function. Choice B is incorrect as the pulse rate typically decreases with age, rather than increases. Choice C is incorrect as there is a general trend of decreasing pulse rate as individuals age, rather than a continuous variation. Choice D is incorrect as the pulse rate does change over a patient's lifespan, starting fast in infants and decreasing as they age.

2. Your patient had a stroke, or CVA, five years ago. The resident still has right-sided weakness. You are ready to transfer the resident from the bed to the wheelchair. The wheelchair should be positioned at the _____________.

A. head of the bed on the patient's right side
B. head of the bed on the patient's left side
C. bottom of the bed on the patient's right side
D. bottom of the bed on the patient's left side

Correct answer: B

Rationale: The wheelchair should be positioned at the head of the bed on the resident's left side. This positioning allows the resident to use their stronger left side to assist with the transfer, compensating for the right-sided weakness. Placing the wheelchair at the head of the bed on the patient's right side (Choice A) would not utilize the stronger left side, which is crucial for the transfer. Similarly, positioning the wheelchair at the bottom of the bed on either side (Choices C and D) would not facilitate optimal assistance from the resident's stronger side during the transfer process.

3. Which technique is correct when assessing the radial pulse of a patient?

A. Palpate for 1 minute if the rhythm is irregular.
B. Palpate for 15 seconds and multiply by 4 if the rhythm is regular.
C. Palpate for 2 full minutes to detect any variation in amplitude.
D. Palpate for 10 seconds and multiply by 6 if the rhythm is regular and the patient has no history of cardiac abnormalities.

Correct answer: A

Rationale: When assessing the radial pulse, if the rhythm is irregular, the pulse should be counted for a full minute to get an accurate representation of the pulse rate. In cases where the rhythm is regular, the recommended technique is to palpate for 15 seconds and then multiply by 4 to calculate the beats per minute. This method is more accurate and efficient for normal or rapid heart rates. Palpating for 30 seconds and multiplying by 2 is not as effective, as any error in counting results in a larger discrepancy in the calculated heart rate. Palpating for 2 full minutes is excessive and not necessary for routine pulse assessment. Palpating for 10 seconds and multiplying by 6 is not a standard technique and may lead to inaccuracies, especially in patients with cardiac abnormalities.

4. When cleansing the genital area during perineal care, the nurse should _____________.

A. cleanse the penis with a circular motion starting from the base and moving toward the tip.
B. replace the foreskin after it has been pushed back to cleanse an uncircumcised penis.
C. cleanse the rectal area first and then clean the patient's genital area.
D. use the same area on the washcloth for each washing and rinsing stroke for a female resident.

Correct answer: B

Rationale: During perineal care, when cleansing the genital area of an uncircumcised male patient, it is crucial to retract the foreskin to clean the area underneath. This helps in the removal of smegma, a substance that can accumulate and lead to bacterial growth and infection if not cleaned properly. The foreskin should then be replaced back to its original position after cleaning to ensure proper hygiene and prevent any potential complications. Choices A, C, and D are incorrect because they do not address the specific care required for an uncircumcised penis, which involves retracting and replacing the foreskin.

5. A 51-year-old woman had an incisional cholecystectomy 6 hours ago. The nurse will place the highest priority on assisting the patient to

A. choose low-fat foods from the menu
B. perform leg exercises hourly while awake
C. ambulate the evening of the operative day
D. turn, cough, and deep breathe every 2 hours

Correct answer: D

Rationale: Postoperative nursing care after a cholecystectomy focuses on preventing respiratory complications due to the surgical incision being high in the abdomen, which impairs coughing and deep breathing. Turning, coughing, and deep breathing every 2 hours help prevent respiratory complications, such as pneumonia. While choices A, B, and C are also important aspects of postoperative care, they are not as high a priority as ensuring proper ventilation and respiratory function in the immediate postoperative period.