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. When examining an older adult, which technique should the nurse use?

A. Minimize touching the patient as much as possible.
B. Attempt to perform the entire physical examination during one visit.
C. Speak loudly and slowly due to potential hearing deficits in aging adults.
D. Arrange the sequence of the examination to allow as few position changes as possible.

Correct answer: D

Rationale: When examining an older adult, it is crucial to arrange the sequence of the examination to minimize position changes. This helps prevent discomfort and fatigue for the older adult, who may have mobility issues. Option A is incorrect because physical touch is essential when examining older adults, as their other senses may be diminished. Option B is incorrect as it is better to break the examination into multiple visits to ensure thoroughness and comfort. Option C is incorrect because while some older adults may have hearing deficits, it is not appropriate to assume this for all individuals without proper assessment.

3. When considering the concepts related to blood pressure, which statement best describes the concept of mean arterial pressure (MAP)?

A. MAP is the pressure of the arterial pulse.
B. MAP reflects the stroke volume of the heart.
C. MAP is the pressure forcing blood into the tissues, averaged over the cardiac cycle.
D. MAP is an average of the systolic and diastolic blood pressures and reflects tissue perfusion.

Correct answer: C

Rationale: Mean Arterial Pressure (MAP) is the pressure that forces blood into the tissues, averaged over the cardiac cycle. It is not the pressure of the arterial pulse (Choice A), nor does it directly reflect the stroke volume of the heart (Choice B). While MAP involves systolic and diastolic pressures, it is not simply an average of these two values as diastole lasts longer. Instead, MAP is closer to diastolic pressure plus one third of the pulse pressure. The best description of MAP is that it represents the pressure forcing blood into the tissues, averaged over the cardiac cycle.

4. What is the MOST ACCURATE statement regarding the ESR test?

A. The results are diagnostic for certain conditions.
B. Abnormal results are indicative of a potentially fatal illness.
C. Abnormal results should be followed by additional testing.
D. Results are reported in millimeters per hour.

Correct answer: C

Rationale: The erythrocyte sedimentation rate (ESR) is a non-specific screening test for inflammation in the body. It is not used as a definitive diagnostic tool for specific conditions. When ESR results are abnormal, they indicate the presence of inflammation, which can be caused by various reasons. Therefore, abnormal results should be followed by additional testing to determine the underlying cause. The ESR test measures the rate at which red blood cells settle in a vertical tube over the span of one hour, and results are reported in millimeters per hour. Choice A is incorrect because ESR results are not solely diagnostic for any specific condition. Choice B is incorrect as abnormal ESR results do not directly indicate a potentially fatal illness without further investigation. Choice D is incorrect as the results are reported in millimeters per hour, not per minute.

5. The abbreviation pc is defined as ________________.

A. before the meal
B. with the meal
C. after the meal
D. post corpi

Correct answer: C

Rationale: The correct answer is C: 'after the meal.' In medical terminology, 'pc' is an abbreviation for 'post cibum,' which means 'after eating' or 'after the meal.' This term is used to indicate when a medication should be taken concerning meals. Choices A, B, and D are incorrect. 'Before the meal' (A) is typically abbreviated as 'ac,' 'with the meal' (B) is abbreviated as 'pc,' and 'post corpi' (D) is not a valid medical abbreviation or term.