a physician may assess turgor when

NCLEX-RN

NCLEX RN Actual Exam Test Bank

1. When is a physician likely to assess turgor?

A. When iron deficiency is suspected.
B. When heart and lung issues are suspected.
C. When dehydration is suspected.
D. None of the above.

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.

2. After receiving change-of-shift report, which patient should the nurse assess first?

A. A patient with pneumonia who has crackles in the right lung base
B. A patient with possible lung cancer who has just returned after bronchoscopy
C. A patient with hemoptysis and a 16-mm induration with tuberculin skin testing
D. A patient with chronic obstructive pulmonary disease (COPD) and pulmonary function testing (PFT) that indicates low forced vital capacity

Correct answer: B

Rationale: The correct answer is the patient with possible lung cancer who has just returned after bronchoscopy. After bronchoscopy, the patient may have decreased cough and gag reflexes, necessitating immediate assessment for airway patency to prevent potential complications. The other patients do not exhibit urgent clinical manifestations or have undergone recent procedures that require immediate attention. Therefore, they can be assessed after ensuring the safety and stability of the patient who has just returned after bronchoscopy.

3. When a patient refuses to believe a terminal diagnosis, they are exhibiting:

A. Regression
B. Mourning
C. Denial
D. Rationalization

Correct answer: C

Rationale: Denial is a defense mechanism where a patient rejects a reality that is too painful or difficult to accept. In the context of a terminal diagnosis, the patient may refuse to believe it in order to avoid facing the harsh truth. Regression (choice A) involves reverting to earlier, more childlike behaviors and is not applicable in this scenario. Mourning (choice B) is the process of grieving a loss, which typically occurs after acceptance of the diagnosis. Rationalization (choice D) is creating logical explanations to justify unacceptable behaviors, which is not the case when a patient denies a terminal diagnosis.

4. Which of these actions illustrates the correct technique for a nurse when assessing oral temperature with a glass thermometer?

A. Wait 30 minutes if the patient has ingested hot or iced liquids.
B. Leave the thermometer in place for 3 to 4 minutes if the patient is afebrile.
C.
D. Place the thermometer at the base of the tongue and ask the patient to close his or her lips.

Correct answer: B

Rationale:

5. When preparing a patient on complete bed rest to eat, at what degree angle or more should you put the head of the bed up?

A. 10
B. 15
C. 20
D. 30

Correct answer: D

Rationale: The correct answer is D: 30. When a patient is on complete bed rest, it is essential to elevate the head of the bed at a 30-degree angle or more before meals. This position helps prevent choking and aspiration of food during eating by promoting proper swallowing and digestion. Choices A, B, and C are incorrect because they do not provide the optimal elevation needed to support safe and effective feeding for a patient on complete bed rest.