NCLEX RN Simulated Exam Test Bank - Nurselytic

Correct Answer: C

Rationale: When adding information to a patient's chart after the encounter, using the term 'Late Entry' is essential. This clearly indicates that the information was added after the fact and helps to maintain the accuracy and integrity of the medical record. Option A is incorrect because removing a page from the chart and rewriting it can lead to inaccuracies and is not a recommended practice for correcting errors. Option B suggests marking the original Chief Complaint as an error, which may not be clear to future readers of the chart and could lead to confusion. Option D is incorrect as it dismisses the correct approach outlined in Option C, which is the best way to handle the situation of missed documentation during a patient encounter.

Correct Answer: B

Rationale: Korotkoff sounds are the sounds that occur when blood flows in an artery that has been temporarily compressed during a blood pressure measurement. These sounds result from the vibration of blood against the artery walls as the pressure cuff is released. There are five distinct phases of Korotkoff sounds, which healthcare providers are trained to identify during blood pressure assessment. The correct answer, choice B, accurately describes the nature of Korotkoff sounds and how they are generated.

Choices A, C, and D are incorrect because Korotkoff sounds are not specific to diastole, not limited to skilled cardiologists, and categorized into five phases, not six.

Correct Answer: B

Rationale: The most accurate method to assess a patient's respiration rate is to count the breaths simultaneously while counting the pulse rate. This approach ensures that the patient is unaware of the specific focus on their breathing, preventing any conscious alteration in breathing patterns.
Choice A is incorrect because informing the patient may lead to altered breathing as the patient may consciously change their breathing pattern.
Choice C involves counting the pulse rate first, which is not necessary for assessing respiration rate.
Choice D is incorrect as it includes unnecessary steps such as taking the patient's temperature before counting respiration rate, which adds no value to accurately assessing the respiration rate.

Correct Answer: C

Rationale: Food intake is typically measured in terms of the percentage (%) of food that has been eaten. Using percentages allows for a more precise and standardized way of recording food consumption. For instance, you would record 25% of the vegetable if the person has eaten about a quarter of the vegetables on the plate.

Choices A and B are incorrect.
Choice A's terms 'a little' and 'a moderate amount' are vague and not specific enough for accurate documentation.
Choice B's use of cc is more appropriate for measuring fluids, not solid foods.
Choice D is also incorrect as it combines vague terms with percentages, which could lead to confusion in accurately documenting the food intake.

Correct Answer: A

Rationale: The correct answer is High Fowler's. Sitting in a chair or resting in a bed in the high Fowler's position helps decrease the cardiac workload and facilitates breathing in clients with congestive heart failure. This position helps reduce venous return and increases lung expansion, improving oxygenation. The supine position (choice
B) may lead to increased pressure on the heart and lungs, making it less suitable for these clients. The left lateral position (choice
C) is not as effective as High Fowler's in reducing cardiac workload and improving breathing. Low Fowler's position (choice
D) does not provide the same benefits as the High Fowler's position for clients with congestive heart failure.