when assessing a 75 year old patient who has asthma the nurse notes that the patient assumes a tripod position leaning forward with arms braced on the
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Nursing Elites

NCLEX-RN

Exam Cram NCLEX RN Practice Questions

1. When assessing a 75-year-old patient who has asthma, the nurse notes that the patient assumes a tripod position, leaning forward with arms braced on the chair. How would the nurse interpret these findings?

Correct answer: D

Rationale: Assuming a tripod position"?leaning forward with arms braced on chair arms"?occurs with chronic pulmonary diseases like asthma. This position helps improve breathing by allowing better use of respiratory muscles. Option A is incorrect because assuming the tripod position is not related to being eager or interested in participating in an interview. Option B is incorrect as abdominal pain is not typically associated with the tripod position in this context. Option C is incorrect as assisting the patient to a supine position would not address the underlying respiratory difficulty indicated by the tripod position. Therefore, the correct interpretation is to recognize that the patient is likely experiencing respiratory difficulties when assuming the tripod position.

2. What is the initial step to take when a patient passes out at the front desk?

Correct answer: C

Rationale: The correct initial step when a patient passes out at the front desk is to shake the patient gently and ask if they are okay. This step aims to assess the patient's level of responsiveness. Checking for a pulse or initiating CPR should only be done if the patient does not respond to being shaken. Calling 911 can be the next step after assessing the patient's immediate condition and providing necessary assistance.

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

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.

4. A client is being seen for disrupted sleep patterns. The nurse encourages the client to verbalize feelings about sleep and inability to maintain adequate sleep habits. What is the rationale for this action?

Correct answer: B

Rationale: Clients experiencing disrupted sleep patterns may have underlying anxiety or fear contributing to their poor sleep habits. Encouraging clients to verbalize their feelings about sleep allows them to address any negative emotions that may be impacting their ability to sleep well. By working through these issues, clients may experience increased peace and relaxation, which can help promote better sleep. Option A is incorrect because assuming a mental illness without evidence can lead to mismanagement of the client's care. Option C is incorrect as it does not address the underlying emotional factors affecting the client's sleep patterns. Option D is incorrect as there is a specific rationale for encouraging the client to verbalize their feelings about sleep.

5. Where is the duodenum located in the digestive system?

Correct answer: D

Rationale: The duodenum is the first part of the small intestine, located immediately after the stomach. It is where the majority of digestion takes place in the gut. The pancreas delivers digestive juices containing amylase and lipase, while the gall bladder delivers bile to aid in the digestion of fats. Choice A incorrectly states that the duodenum is the third section of the small intestine, which is inaccurate. Choice B incorrectly associates the duodenum with the gall bladder, which is not where the duodenum is located. Choice C incorrectly states that the duodenum is where the pancreas delivers digestive juices, which is partly correct but not the main function of the duodenum. Therefore, the correct answer is 'None of the above' as none of the choices accurately describe the location or functions of the duodenum.

Similar Questions

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 75-year-old man with a history of hypertension was recently changed to a new antihypertensive drug. He reports feeling dizzy at times. How would the nurse evaluate his blood pressure?
Which nursing intervention is the highest priority for a client at risk for falls in a hospital setting?
A physician has ordered that a client must be placed in a high Fowler's position. How does the nurse position this client?
The client reports nausea and constipation. Which of the following would be the priority nursing action?

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