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

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?

A. Interpret that the patient is eager and interested in participating in the interview.
B. Evaluate the patient for abdominal pain, which may be exacerbated in the sitting position.
C. Interpret that the patient is having difficulty breathing and assist them to a supine position.
D. Recognize that a tripod position is often used when a patient is having respiratory difficulties.

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 most effective step in hand washing?

A. Using friction to remove potential pathogens.
B. Using hospital-grade soap.
C. Moisturizing the hands after washing to prevent cracking.
D. Washing hands with soap for at least 15 seconds.

Correct answer: A

Rationale: The most effective step in hand washing is using friction to remove potential pathogens. While using soap, moisturizing hands, and washing for a sufficient duration are important aspects of hand hygiene, the mechanical action of rubbing hands together with friction is crucial in dislodging and removing dirt, debris, and potential pathogens. Hospital-grade soap may be beneficial, but the physical act of friction is key to effective hand washing. Moisturizing after washing is important for skin health but not the most effective step in the hand washing process. Simply washing hands for a specific duration, such as 15 seconds, without proper friction may not effectively remove contaminants. Therefore, using friction for thorough cleaning is the most crucial step in hand washing.

3. Which of the following statements best describes footdrop?

A. The foot is permanently fixed in the dorsiflexion position
B. The foot is permanently fixed in the plantar flexion position
C. The toes of the foot are permanently fanned
D. The heel of the foot is permanently rotated outward

Correct answer: B

Rationale: Footdrop results in the foot becoming permanently fixed in a plantar flexion position, not dorsiflexion. This position points the toes downward. The client may be unable to put weight on the foot, making ambulation difficult. Footdrop can be caused by immobility or chronic illnesses that cause muscle changes, such as multiple sclerosis or Parkinson's disease. Choice A is incorrect because footdrop leads to plantar flexion, not dorsiflexion. Choice C is incorrect as it describes a different condition known as 'toe fanning.' Choice D is incorrect as it describes an external rotation of the heel, which is not a characteristic of footdrop.

4. Which of these actions illustrates the correct technique for a nurse when assessing oral temperature with a glass thermometer?

A. Wait 30 minutes if the patient has ingested hot or iced liquids.
B. Leave the thermometer in place for 3 to 4 minutes if the patient is afebrile.
C. Shake the glass thermometer down to 35.5�C before taking the patient's temperature.
D. Place the thermometer at the base of the tongue and ask the patient to close his or her lips.

Correct answer: B

Rationale: The correct technique for assessing oral temperature with a glass thermometer involves leaving the thermometer in place for 3 to 4 minutes if the patient is afebrile and up to 8 minutes if the patient is febrile. Waiting 30 minutes if the patient has ingested hot or iced liquids is incorrect; instead, the nurse should wait 15 minutes in such cases. Shaking the glass thermometer down to 35.5�C, not 37.5�C, is the correct procedure before taking the patient's temperature. Placing the thermometer at the base of the tongue, not the front, and asking the patient to close their lips is the proper way to position the thermometer. Therefore, the correct answer is to leave the thermometer in place for 3 to 4 minutes if the patient is afebrile and up to 8 minutes if the patient is febrile.

5. What is the purpose of MSDS sheets?

A. Contain the ordering information for each piece of equipment in the office.
B. Are required by OSHA to be accessible to all employees of the office.
C. Can be used to treat patients who have been injured in equipment accidents.
D. None of the above.

Correct answer: B

Rationale: MSDS sheets, also known as Materials Safety Data Sheets, are essential documents that provide detailed information about chemicals used in the workplace. They are required by OSHA to be easily accessible to all employees to ensure they have the necessary information to handle chemicals safely. MSDS sheets do not contain ordering information for equipment in the office (Choice A) or serve as a treatment guide for injured patients (Choice C). Therefore, the correct answer is that MSDS sheets are required by OSHA to be accessible to all employees of the office.