to accurately assess a patients respiration rate which of the following methods would be best

NCLEX-RN

NCLEX RN Actual Exam Test Bank

1. To accurately assess a patient's respiration rate, which of the following methods would be BEST?

A. Tell the patient, 'Please remain silent while I count your number of breaths.'
B. Count respirations at the same time you are counting the pulse rate
C. Count the pulse rate for one minute, then, while keeping your index fingers on the patient's radial artery, count the respirations for an additional minute.
D. Count the patient's respiration rate, then take the patient's temperature, and then take the pulse rate.

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.

2. What action by the nurse is appropriate when examining a 16-year-old male teenager?

A. Discuss health teaching with the teenager to promote wellness.
B. Ask the parent to step out of the room during the history and physical examination to respect the teenager's privacy.
C. Use age-appropriate communication when speaking to the teenager to ensure understanding.
D. Provide feedback that his body is developing normally and discuss the wide variation among teenagers on the rate of growth and development.

Correct answer: D

Rationale: During the examination of a 16-year-old male teenager, it is essential to provide feedback that his body is developing normally and to discuss the wide variation among teenagers regarding growth and development. This reassures the teenager about his health status and addresses any concerns about physical development. It is important to recognize that adolescents are very conscious of their body image and often compare themselves to their peers, hence the need for such feedback. Asking the parent to step out of the room respects the teenager's privacy and promotes open communication between the nurse and the teenager. Using age-appropriate communication is crucial to ensure that the teenager understands the information provided. Asking the parent to stay in the room may not be ideal as it can inhibit open discussion, and talking to the teenager as if they were a younger child is inappropriate and may undermine their autonomy and understanding.

3. Intermittent fevers are:

A. fevers which come and go.
B. fevers which rise and fall but are always considered above the patient's average temperature.
C. fevers which fluctuate more than three degrees and never return to normal.
D. None of the above.

Correct answer: A

Rationale: Intermittent fevers are characterized by periods of fever followed by periods of normal body temperature. They alternate between being febrile and afebrile. Continuous fevers show minimal fluctuations over a 24-hour period, while remittent fevers fluctuate significantly but do return to normal body temperature. Choice A is correct as it accurately describes intermittent fevers. Choices B and C are incorrect as they do not fully capture the defining characteristic of intermittent fevers, which involve cyclical episodes of fever and normal temperature. Choice D is incorrect as there is a specific definition for intermittent fevers.

4. Which of the following is one of the three smallest bones in the body?

A. Vomer
B. Distal phalanx of the small toe
C. Stapes
D. Coccyx

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.

5. Who is legally able to make decisions for the patient or resident during a patient care conference when the patient is not mentally able to make decisions on their own?

A. The patient or their healthcare proxy
B. Only the patient
C. Only the healthcare proxy
D. The doctor

Correct answer: C

Rationale: When a patient is unable to make decisions due to mental incapacity, the healthcare proxy, designated by the patient in advance, has the legal authority to make decisions on the patient's behalf. In this situation, the patient lacks the capacity to make decisions independently. The healthcare proxy's role is to represent the patient's wishes and best interests. The doctor's role in a patient care conference is to provide medical expertise, offer recommendations, and assist in the decision-making process, but the final decision-making authority lies with the healthcare proxy, not the doctor.