which of the following would be most important for the nurse to keep in mind regarding the use of side rails for a confused patient
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Nursing Elites

NCLEX-RN

NCLEX RN Predictor Exam

1. Which of the following would be most important for the nurse to keep in mind regarding the use of side rails for a confused patient?

Correct answer: A

Rationale: When considering the use of side rails for a confused patient, it is crucial for the nurse to understand that individuals of small stature are at a higher risk for injury from entrapment. Studies have shown that people of small stature are more likely to slip through or between the side rails, making them vulnerable to harm. It is essential to prioritize patient safety and avoid potential risks associated with entrapment. Conversely, a history of previous falls from a bed with raised side rails is significant as it indicates a heightened risk for future serious incidents. The desire to prevent a patient from wandering alone does not justify the use of side rails; instead, alternative measures should be creatively employed to respect the patient's dignity and avoid more serious fall-related injuries.

2. The abbreviation ac is defined as _____________.

Correct answer: A

Rationale: The correct answer is 'before the meal.' The abbreviation 'ac' is derived from the Latin term 'ante cibum,' which translates to 'before a meal.' Choices B, C, and D are incorrect because 'ac' does not refer to 'with the meal,' 'after the meal,' or 'ante corpis.' It specifically denotes something occurring before a meal, making option A the correct choice in this context.

3. A patient's body temperature has varied over the last 24 hours from 97.6 degrees F in the morning to 99 degrees F in the evening. The patient is worried that this change in temperature may indicate the beginning of a fever. Which of the following BEST explains this phenomenon?

Correct answer: B

Rationale: The patient is experiencing changes related to a diurnal rhythm. Diurnal rhythm is the phenomenon of body temperature fluctuating depending on the time of day. Temperatures taken in the morning are typically lower than those taken throughout the rest of the day. Choice A is incorrect because a single elevated temperature reading in the evening does not definitively indicate a fever. Choice C is incorrect as there is no indication of incorrect temperature measurement. Choice D is incorrect as the temperature changes are not related to monthly hormones but rather to the body's natural daily rhythm.

4. A patient's urine tests positive for glucose. The doctor asks you to confirm this finding. Which of the following would BEST confirm this finding?

Correct answer: C

Rationale: To confirm glucosuria, the most appropriate method is to run a Clinitest. Clinitest tablets are specifically designed to detect glucose in urine samples. This test is particularly useful when the urine is discolored, making it challenging to accurately assess the color change.\n Choice A, using a hand-held glucometer, is not the standard method for confirming glucose in urine; these devices are primarily used for blood glucose monitoring.\n Choice B, having another Medical Assistant perform a repeat dipstick test, may not provide a more definitive confirmation as dipstick tests can sometimes yield false positives or be less accurate compared to other methods like the Clinitest.\n Choice D, running an Acetest, is used to detect ketones in the urine, not glucose. Ketones are typically associated with conditions like diabetic ketoacidosis, which is different from glucosuria.

5. A patient with Parkinson's disease is experiencing difficulty swallowing. What potential problem associated with dysphagia has the greatest influence on the plan of care?

Correct answer: B

Rationale: When a person experiences dysphagia (difficulty swallowing), the greatest concern is aspiration. Aspiration occurs when food or fluids enter the trachea and lungs instead of going down the esophagus. This can lead to serious complications such as choking, airway obstruction, and aspiration pneumonia. Anorexia (Choice A) refers to a loss of appetite, which is not the primary concern with dysphagia. Self-care deficit (Choice C) and inadequate intake (Choice D) are important considerations but do not have as direct an impact on the immediate safety and health risks associated with aspiration in dysphagia.

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