NCLEX RN Simulated Exam Test Bank - Nurselytic

Correct Answer: C

Rationale: Tachypnea is defined as a rapid, quick, and shallow respiration rate. When a patient is anxious, they may hyperventilate, leading to tachypnea. Bradypnea (
Choice
A) is slow breathing, which is not expected in an anxious patient. Orthopnea (
Choice
B) is difficulty breathing while lying down and is not directly related to anxiety. Dyspnea (
Choice
D) is shortness of breath, which may not be the primary respiratory pattern seen in an anxious patient undergoing a procedure.
Therefore, the correct choice is tachypnea as it aligns with the expected respiratory response to anxiety.

Correct Answer: A

Rationale: The most appropriate position for an infant after surgical intervention for imperforate anus is the prone position. Placing the infant in a prone position helps keep the hips elevated, reducing edema and pressure on the surgical site. This position promotes optimal healing and comfort for the infant. Option B, supine with no head elevation, does not provide the necessary elevation to reduce pressure on the surgical site. Option C, side-lying with the legs extended, does not offer the same benefits as the prone position in terms of reducing pressure on the surgical site. Option D, supine with the head elevated 45 degrees, does not specifically address the need for hip elevation to prevent pressure on the surgical site.
Therefore, the correct choice is the prone position for this postoperative care scenario.

Correct Answer: A

Rationale: The term 'retroperitoneal' refers to organs positioned behind the peritoneum. The kidneys are retroperitoneal organs, located outside the peritoneal cavity, against the posterior abdominal wall. This positioning provides them with additional protection from external forces due to the surrounding structures. The thymus, small intestines, and spleen are not retroperitoneal organs. The thymus is located in the mediastinum, the small intestines are intraperitoneal, and the spleen is intraperitoneal and located in the left upper quadrant of the abdomen.

Correct Answer: D

Rationale: By using a demonstration and performance method of patient education, the patient is offered a chance to perform a task and have learning assessed while still in the office. This ensures that any questions that the patient has can be answered immediately, and any performance issues observed by the medical assistant can also be corrected promptly.
Choice A is not as effective as providing a demonstration in person, as it may not address the patient's specific learning needs or allow for immediate feedback.
Choice B suggests asking a healthcare provider to demonstrate, which is similar to the correct answer but may not always be readily available in the office.
Choice C, watching a video, lacks the interactive component and immediate feedback that a live demonstration provides, making it less effective in this scenario.

Correct Answer: A

Rationale: When a physician's order specifies taking a temperature at the axilla, the nurse should place the thermometer in the armpit. The axilla is the anatomical area of the armpit located under the arms, proximal to the trunk. Placing the thermometer in the rectum (
Choice
A) is used for rectal temperature measurements, in the mouth (
Choice
B) for oral temperature measurements, and on the temples (
Choice
C) is not a common site for temperature assessment.
Therefore, the correct placement based on the given instruction is in the armpit.