you have been assigned to take an apical pulse for one of the patients on the nursing unit how will you do this

NCLEX-RN

NCLEX RN Actual Exam Test Bank

1. You have been assigned to take an apical pulse for one of the patients on the nursing unit. How will you do this?

A. You will place the stethoscope over the heart and listen for any irregular beats.
B. You will place the stethoscope over the heart and count the beats per minute.
C. You will place your fingertip over the patient's wrist and feel for any irregular beats.
D. You will place your fingertip over the patient's wrist and count the beats per minute.

Correct answer: B

Rationale: To take an apical pulse accurately, you should place the stethoscope over the heart and count the number of beats per minute. This method provides a precise assessment of the heart rate. While listening for irregular beats is essential for assessing the heart's rhythm, the primary objective of taking an apical pulse is to determine the heart rate. Choices C and D are incorrect because the apical pulse is not taken at the wrist; instead, it is obtained by auscultating at the apex of the heart, usually at the point where the fifth intercostal space meets the midclavicular line.

2. To properly read a meniscus,

A. hold the measuring device at eye level and read the bottom of the curve of the liquid level
B. hold the measuring device at eye level and read the top of the curve of the liquid level where the liquid adheres to the walls of the container.
C. hold the measuring device at table level and, looking down into the measuring device, read the bottom of the curve of the liquid level.
D. hold the measuring device at table level and, looking down into the measuring device, read the top of the curve of the liquid level.

Correct answer: A

Rationale: To properly read a meniscus, it is essential to hold the measuring device at eye level to avoid parallax error. Reading the bottom of the curve of the liquid level is correct because the meniscus is the concave or convex curve at the liquid's surface. Choice B is incorrect because reading the top of the curve where the liquid adheres to the walls of the container can lead to inaccurate measurements. Choices C and D are incorrect as they suggest holding the device at table level, which can introduce parallax error and result in an incorrect reading.

3. What does the medical term 'basophilia' refer to?

A. An attachment of the epithelial cells of the skin to a basement membrane
B. An overabundance of a particular white blood cell in the peripheral blood
C. An underrepresentation of basophils on a blood smear
D. None of the above

Correct answer: B

Rationale: The correct answer is 'An overabundance of a particular white blood cell in the peripheral blood.' Basophilia specifically indicates an increased number of basophils in the peripheral blood. It can be observed in conditions like leukemia and certain allergic reactions. Choice A is incorrect as it describes something unrelated to basophilia. Choice C is incorrect as it suggests a decrease in basophils, which is opposite to the actual meaning of basophilia. Choice D is also incorrect as basophilia does have a defined medical significance.

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. Which theory reflects the view that illness is caused by an imbalance or disharmony in the forces of nature?

A. Germ theory
B. Naturalistic theory
C. Magicoreligious theory
D. Biomedical or scientific theory

Correct answer: B

Rationale: The naturalistic theory posits that illness results from an imbalance or disharmony in the forces of nature. According to this theory, maintaining a natural balance or harmony is essential to prevent illness. Conversely, germ theory and biomedical or scientific theory attribute illness to microorganisms, while magicoreligious theory attributes illness to supernatural forces such as deities or spirits. Therefore, the most appropriate theory reflecting the belief that illness arises from a disruption in natural forces is the naturalistic theory.