NCLEX RN Simulated Exam Test Bank - Nurselytic

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.

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: C

Rationale: The mitral valve, also known as the bicuspid valve, is located between the left atrium and the left ventricle, regulating blood flow from the left atrium into the left ventricle. The term 'bicuspid' refers to the valve's two cusps or leaflets. This distinguishes it from the tricuspid valve (
Choice
D), which has three cusps, making
Choice D incorrect. The left ventricle (
Choice
A) and right atrium (
Choice
B) are not synonymous with the mitral valve.
Therefore, the correct answer is C: Bicuspid valve.

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.

Correct Answer: B

Rationale: The correct answer is B: The apical pulse method is used on infants. This method involves placing a stethoscope in the fifth intercostal space, mid-clavicular line, and counting the beats for a full minute. It is a preferred method for infants due to their small size and the difficulty in palpating peripheral pulses accurately.

Choices A, C, and D are incorrect.
Choice A is incorrect as pulse rates are indeed taken on infants, albeit using a different method.
Choice C is incorrect as a sphygmomanometer is typically used for measuring blood pressure, not pulse rates.
Choice D is incorrect as pulse rates on infants are usually taken apically in the fifth intercostal space, not the third.