the rule of nines is used to

NCLEX-RN

Safe and Effective Care Environment NCLEX RN Questions

1. The Rule of Nines is used to:

A. determine the amount of the body surface that has been burned
B. assess the level of oxygen saturation in a body that has been burned.
C. determine the level of tissue damage that has occurred in a burn.
D. None of the above.

Correct answer: A

Rationale: The Rule of Nines is used to assess the amount of body surface that has been burned. Most body areas are divided out based on 9%, with the exception of the genitalia, which is only 1%.

2. When assessing a 75-year-old patient who has asthma, the nurse notes that the patient assumes a tripod position, leaning forward with arms braced on the chair. How would the nurse interpret these findings?

A. Interpret that the patient is eager and interested in participating in the interview.
B. Evaluate the patient for abdominal pain, which may be exacerbated in the sitting position.
C. Interpret that the patient is having difficulty breathing and assist them to a supine position.
D. Recognize that a tripod position is often used when a patient is having respiratory difficulties.

Correct answer: D

Rationale: Assuming a tripod position"?leaning forward with arms braced on chair arms"?occurs with chronic pulmonary diseases like asthma. This position helps improve breathing by allowing better use of respiratory muscles. Option A is incorrect because assuming the tripod position is not related to being eager or interested in participating in an interview. Option B is incorrect as abdominal pain is not typically associated with the tripod position in this context. Option C is incorrect as assisting the patient to a supine position would not address the underlying respiratory difficulty indicated by the tripod position. Therefore, the correct interpretation is to recognize that the patient is likely experiencing respiratory difficulties when assuming the tripod position.

3. When counting an infant's respirations, which technique is correct?

A. Watching the chest rise and fall
B. Observing the movement of the abdomen
C. Placing a hand across the infant's chest
D. Using a stethoscope to listen to the breath sounds

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.

4. The nurse supervises unlicensed assistive personnel (UAP) who are providing care for a patient with right lower lobe pneumonia. The nurse should intervene if which action by UAP is observed?

A. UAP splint the patient's chest during coughing.
B. UAP assist the patient to ambulate to the bathroom.
C. UAP help the patient to a bedside chair for meals.
D. UAP lower the head of the patient's bed to 15 degrees.

Correct answer: D

Rationale: The correct action for the nurse to intervene in is when the UAP lowers the head of the patient's bed to 15 degrees. This position can decrease ventilation in a patient with pneumonia, potentially worsening their condition. Choices B and C involve assisting the patient with activities of daily living and promoting mobility, which are appropriate for the patient's care. Choice A, splinting the patient's chest during coughing, can help the patient manage coughing effectively, which is also appropriate for a patient with pneumonia.

5. What type of blood pressure measurement error is most likely to occur if the nurse does not check for the presence of an auscultatory gap?

A. Diastolic blood pressure may not be heard.
B. Diastolic blood pressure may be falsely low.
C. Systolic blood pressure may be falsely low.
D. Systolic blood pressure may be falsely high.

Correct answer: C

Rationale: If an auscultatory gap is undetected, a falsely low systolic reading may occur. This gap can lead to an underestimation of the systolic blood pressure, causing potential misinterpretation of the patient's condition. The diastolic blood pressure may not be heard due to the gap, but the critical issue in this scenario is the risk of underestimating systolic blood pressure, which can impact clinical decision-making. Choices B, C, and D are incorrect because the key concern in this context is the potential for a falsely low systolic blood pressure reading when an auscultatory gap is not assessed.