NCLEX RN Simulated Exam Test Bank - Nurselytic

Correct Answer: A

Rationale: The Lymphatic System is responsible for maintaining fluid balance and supporting immunity. It contains organs like the spleen, tonsils, thymus, lymph nodes, and lymph vessels. The spleen, a part of the lymphatic system, plays a crucial role in filtering blood and storing blood cells. The Digestive System is primarily involved in the breakdown and absorption of nutrients, not fluid balance or immunity. The Urinary System is responsible for filtering waste products from the blood and regulating fluid balance, but it does not support immunity or contain the spleen. The Respiratory System is focused on gas exchange and oxygenating the blood, not fluid balance or immunity.

Correct Answer: C

Rationale: Skin turgor is assessed when dehydration is suspected.
To evaluate skin turgor, a physician pinches the skin and observes how quickly it returns to its normal position. If the skin stays folded for an extended period, it indicates dehydration. Assessing turgor helps determine a patient's hydration status.
Choice A is incorrect because skin turgor is not used to assess iron deficiency.
Choice B is incorrect as turgor is not related to heart and lung issues, but rather hydration status.
Choice D is incorrect as turgor assessment is relevant when dehydration is suspected.

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: 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: C

Rationale: The correct answer is counting the pulse for 15 seconds and multiplying the number by four.
To accurately assess a patient's heart rate or pulse, it is crucial to count the pulse for a full minute. Counting for only 15 seconds and then multiplying by four may result in an inaccurate heart rate calculation. This approach could miss arrhythmias or intermittent pulsations that could be vital indicators of the patient's condition. Placing the index finger on the radial artery, which is located on the thumb side of the patient's wrist, is the correct technique for taking a pulse. Noting a pulse as 'weak' when the pulsation disappears upon adding pressure is a valid observation and not an error in itself.
Therefore, the most common error in this scenario is incorrectly calculating the pulse rate by multiplying a 15-second count by four.