Exam Cram NCLEX RN Practice Questions - Nurselytic

Correct Answer: C

Rationale: Patients who are unable to move in bed are at high risk of developing pressure ulcers and skin breakdown due to prolonged pressure on specific body areas. Turning these patients at least every 2 hours is crucial to relieve pressure, improve circulation, and prevent skin damage. More frequent turning may be necessary for patients with specific needs, such as those who are incontinent of urine and require additional care. Turning patients less frequently, such as once a day, twice a day, or every 4 hours, increases the risk of developing pressure ulcers and other complications.
Therefore, the correct answer is to turn patients who cannot move in their bed on their own every 2 hours.

Correct Answer: A

Rationale: When evaluating the temperature of older adults, it is important to note that their body temperature is usually lower than that of younger adults, with a mean temperature of 36.2°C.
Choice B is incorrect because an older adult's body temperature is not approximately the same as that of a young child.
Choice C is incorrect because body temperature is a physiological parameter and does not vary based on the type of thermometer used.
Choice D is incorrect because while older adults may have less effective heat control mechanisms, their body temperature is typically lower, not widely fluctuating.

Correct Answer: C

Rationale: Mean Arterial Pressure (MAP) is the pressure that forces blood into the tissues, averaged over the cardiac cycle. It is not the pressure of the arterial pulse (
Choice
A), nor does it directly reflect the stroke volume of the heart (
Choice
B). While MAP involves systolic and diastolic pressures, it is not simply an average of these two values as diastole lasts longer. Instead, MAP is closer to diastolic pressure plus one third of the pulse pressure. The best description of MAP is that it represents the pressure forcing blood into the tissues, averaged over the cardiac cycle.

Correct Answer: D

Rationale: The primary responsibility of the charge nurse for a blind and deaf patient is to provide a secure environment. Ensuring patient safety is crucial to prevent medical errors and adverse outcomes. By creating a safe environment, the nurse can protect the patient from harm and promote well-being. Option A is incorrect as the focus should be on ensuring patient safety rather than highlighting deficits. Option B is not the primary responsibility in this scenario, as the immediate concern is the patient's safety. Option C is irrelevant and does not address the patient's primary needs, which are safety and security.

Correct Answer: B

Rationale: The correct technique for counting an infant's respirations is to observe the movement of the abdomen. Infants typically have more diaphragmatic breathing than thoracic, so watching the abdomen provides a more accurate count. Placing a hand on the chest or listening with a stethoscope can alter the infant's breathing pattern and provide inaccurate results.
Therefore, options A, C, and D are incorrect methods for counting an infant's respirations. By observing the movement of the abdomen, healthcare providers can accurately assess an infant's respiratory rate without influencing their breathing pattern.