the rule of nines is used to

NCLEX-RN

Safe and Effective Care Environment NCLEX RN Questions

1. 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%.

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. 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.

4. Which of the following sets of word parts means 'Pain'?

A. dynia and -algia
B. a- and an
C. ia and -ac
D. pathy and -osis

Correct answer: A

Rationale: The correct answer is 'dynia and -algia.' The word parts 'dynia' and '-algia' specifically relate to pain. 'Dynia' refers to pain, and '-algia' also denotes pain. Therefore, when combined, they form the meaning 'pain.' Choices B, C, and D are incorrect because 'a-' and 'an' do not relate to pain, 'ia' and '-ac' do not specifically convey pain, and 'pathy' and '-osis' are not word parts that directly signify pain.

5. After a symptom is recognized, the first effort at treatment is often self-treatment. Which of the following statements is true about self-treatment?

A. "Not recognized as valuable by most health care providers."?
B. "Usually ineffective and may delay more effective treatment."?
C. "Always less expensive than biomedical alternatives."?
D. "Influenced by the accessibility of over-the-counter medicines."?

Correct answer: D

Rationale: After a symptom is identified, the first effort at treatment is often self-treatment. The availability of over-the-counter medications, the relatively high literacy level of Americans, and the influence of the internet and mass media in communicating health-related information to the general population have contributed to the high percentage of cases of self-treatment. Health care providers are recognizing the value of a wide variety of alternative, complementary, and traditional interventions. Many self-treatments, such as over-the-counter medications, are effective. Self-treatment is not always less expensive. Choice A is incorrect as health care providers are recognizing the value of self-treatment. Choice B is incorrect because self-treatment can be effective in many cases. Choice C is incorrect as self-treatment is not always less expensive; it depends on the specific treatment being used.