the nurse is counting an infants respirations which technique is correct

NCLEX-RN

Exam Cram NCLEX RN Practice Questions

1. When counting an infant's respirations, which technique is correct?

A. Watching the chest rise and fall
B. Observing the movement of the abdomen
C. Placing a hand across the infant's chest
D. Using a stethoscope to listen to the breath sounds

Correct answer: B

Rationale: The correct technique for counting an infant's respirations is to observe the movement of the abdomen. Infants typically have more diaphragmatic breathing than thoracic, so watching the abdomen provides a more accurate count. Placing a hand on the chest or listening with a stethoscope can alter the infant's breathing pattern and provide inaccurate results. Therefore, options A, C, and D are incorrect methods for counting an infant's respirations. By observing the movement of the abdomen, healthcare providers can accurately assess an infant's respiratory rate without influencing their breathing pattern.

2. Intermittent fevers are:

A. fevers which come and go.
B. fevers which rise and fall but are always considered above the patient's average temperature.
C. fevers which fluctuate more than three degrees and never return to normal.
D. None of the above.

Correct answer: A

Rationale: Intermittent fevers are characterized by periods of fever followed by periods of normal body temperature. They alternate between being febrile and afebrile. Continuous fevers show minimal fluctuations over a 24-hour period, while remittent fevers fluctuate significantly but do return to normal body temperature. Choice A is correct as it accurately describes intermittent fevers. Choices B and C are incorrect as they do not fully capture the defining characteristic of intermittent fevers, which involve cyclical episodes of fever and normal temperature. Choice D is incorrect as there is a specific definition for intermittent fevers.

3. The nurse is unable to palpate the right radial pulse on a patient. What would the nurse do next?

A. Auscultate over the area with a fetoscope.
B. Use a goniometer to measure the pulsations.
C. Use a Doppler device to check for pulsations over the area.
D. Check for the presence of pulsations with a stethoscope.

Correct answer: C

Rationale: When a nurse is unable to palpate a radial pulse, the next step is to use a Doppler device to check for pulsations over the area. Doppler devices are specifically designed to augment pulse or blood pressure measurements. Auscultating with a fetoscope is used to listen to fetal heart tones and is not relevant in this scenario. Goniometers are used to measure joint range of motion and are not used to assess pulses. Stethoscopes are primarily used to auscultate breath, bowel, and heart sounds, not to check for pulsations in peripheral pulses. Therefore, the correct course of action when unable to palpate a pulse is to utilize a Doppler device to assess for pulsations in the radial pulse area.

4. During an assessment, a nurse asks a patient, "If you had fever and vomiting for 3 days, what would you do?"? Which aspect of the mental status examination is the nurse assessing?

A. Behavior
B. Cognition
C. Affect and mood
D. Perceptual disturbances

Correct answer: B

Rationale: The nurse is assessing cognition in this scenario. Cognition involves evaluating a patient's judgment and decision-making abilities. By asking the patient what they would do in a specific situation, the nurse aims to determine the patient's cognitive function. A correct response indicating intact cognition would involve a decision like 'Call my doctor.' If the patient suggests inappropriate actions like 'I would stop eating' or 'I would just wait and see what happened,' it would suggest impaired judgment. The other options, behavior, affect and mood, and perceptual disturbances, refer to different aspects of the mental status examination and are not directly assessed through this question.

5. A nurse is caring for newborn infants in a nursery when a man enters the area to take his baby back to the room. The man does not have an identification bracelet, and the nurse does not recognize him. What is the next action of the nurse?

A. Call security and ask them to escort the man out of the nursery
B. Ask the man to wait and check the infant's chart
C. Ask the man to return to his room and bring an identification band
D. Allow the man to take the baby to his room

Correct answer: C

Rationale: The safety of infants in newborn nurseries is maintained by requiring parents to wear identification bracelets to identify themselves as the rightful parents. This practice minimizes the risk of mistakenly allowing an unauthorized individual to take a baby. In this scenario, since the nurse does not recognize the man and he lacks an identification bracelet, the appropriate action is to ask him to return to his room and bring the identification band. This step ensures the proper identity verification before allowing the man to take the baby. Calling security without first verifying the man's identity may escalate the situation unnecessarily. Checking the infant's chart alone does not confirm the man's identity. Allowing the man to take the baby without proper verification poses a safety risk to the infant.