which of the following would be most important for the nurse to keep in mind regarding the use of side rails for a confused patient

NCLEX-RN

NCLEX RN Predictor Exam

1. Which of the following would be most important for the nurse to keep in mind regarding the use of side rails for a confused patient?

A. A person of small stature is at increased risk for injury from entrapment.
B. A history of a previous fall from a bed with raised side rails is significant.
C. The desire to prevent a patient from wandering is not sufficient reason for the use of side rails.
D. Creative use of alternative measures indicates respect for the patient's dignity.

Correct answer: A

Rationale: When considering the use of side rails for a confused patient, it is crucial for the nurse to understand that individuals of small stature are at a higher risk for injury from entrapment. Studies have shown that people of small stature are more likely to slip through or between the side rails, making them vulnerable to harm. It is essential to prioritize patient safety and avoid potential risks associated with entrapment. Conversely, a history of previous falls from a bed with raised side rails is significant as it indicates a heightened risk for future serious incidents. The desire to prevent a patient from wandering alone does not justify the use of side rails; instead, alternative measures should be creatively employed to respect the patient's dignity and avoid more serious fall-related injuries.

2. The instructor is teaching a class on basic assessment skills. Which of the following statements is true regarding the stethoscope and its use?

A. Slope of the earpieces should point forward toward the examiner's nose.
B. It blocks out extraneous room noise but does not magnify sound.
C. The tubing length should be 14 to 18 inches to prevent sound distortion.
D. Both fit and quality of the stethoscope are important.

Correct answer: B

Rationale: The stethoscope does not magnify sound but effectively blocks out extraneous room noises. The correct orientation of the earpieces is with the slope pointing forward toward the examiner's nose, not posteriorly. The tubing length of a stethoscope should ideally be between 14 to 18 inches (36 to 46 cm) to avoid sound distortion. Using tubing longer than this range can distort sound. Both the fit and quality of the stethoscope are crucial for accurate auscultation and assessment, highlighting their significance in clinical practice. Therefore, the correct answer is that the stethoscope blocks out extraneous room noise but does not magnify sound.

3. Which technique is correct when assessing the radial pulse of a patient?

A. Palpate for 1 minute if the rhythm is irregular.
B. Palpate for 15 seconds and multiply by 4 if the rhythm is regular.
C. Palpate for 2 full minutes to detect any variation in amplitude.
D. Palpate for 10 seconds and multiply by 6 if the rhythm is regular and the patient has no history of cardiac abnormalities.

Correct answer: A

Rationale: When assessing the radial pulse, if the rhythm is irregular, the pulse should be counted for a full minute to get an accurate representation of the pulse rate. In cases where the rhythm is regular, the recommended technique is to palpate for 15 seconds and then multiply by 4 to calculate the beats per minute. This method is more accurate and efficient for normal or rapid heart rates. Palpating for 30 seconds and multiplying by 2 is not as effective, as any error in counting results in a larger discrepancy in the calculated heart rate. Palpating for 2 full minutes is excessive and not necessary for routine pulse assessment. Palpating for 10 seconds and multiplying by 6 is not a standard technique and may lead to inaccuracies, especially in patients with cardiac abnormalities.

4. A leukemia patient has a relative who wants to donate blood for transfusion. Which of the following donor medical conditions would prevent this?

A. A history of hepatitis C five years previously
B. Cholecystitis requiring cholecystectomy one year previously
C. Asymptomatic diverticulosis
D. Crohn's disease in remission

Correct answer: A

Rationale: A history of hepatitis C five years previously would prevent a donor from donating blood for transfusion. Hepatitis C is a viral infection transmitted through bodily fluids, such as blood, causing inflammation of the liver. Patients with hepatitis C may not donate blood for transfusion due to the high risk of infection in the recipient. Cholecystitis requiring cholecystectomy one year previously, asymptomatic diverticulosis, and Crohn's disease in remission are not contraindications for blood donation as they do not pose a risk of transmitting infections to the recipient.

5. Which of the following is one of the three smallest bones in the body?

A. Vomer
B. Distal phalanx of the small toe
C. Stapes
D. Coccyx

Correct answer: C

Rationale: The stapes, along with the malleus and incus, are the three smallest bones in the human body. These bones are located in the inner ear and play a crucial role in hearing. The vomer is a bone in the nasal cavity and is not one of the smallest bones. The distal phalanx of the small toe is relatively larger and not among the smallest bones. The coccyx, also known as the tailbone, is not one of the smallest bones in the body.