NCLEX RN Exam Preview Answers

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A patient has suddenly developed shortness of breath and appears to be in significant respiratory distress. After calling the physician and placing the patient on oxygen, which of these actions is the best for the nurse to take when further assessing the patient?

  • A. Count the patient's respirations.
  • B. Bilaterally percuss the thorax, noting any differences in percussion tones.
  • C. Call for a chest x-ray and wait for the results before beginning an assessment.
  • D. Inspect the thorax for any new masses and bleeding associated with respirations.
Correct Answer: B

Rationale: In a situation where a patient is in significant respiratory distress, bilaterally percussing the thorax to note any differences in percussion tones is a crucial nursing intervention. Percussion provides instant feedback regarding changes in underlying tissue density, which can give important clues about the patient's physical status. This hands-on assessment technique is readily available and can be performed promptly. Counting the patient's respirations, while important, may not provide as much detailed information as percussion. Ordering a chest x-ray and waiting for the results can cause a delay in assessing and addressing the patient's immediate needs. Inspecting the thorax for new masses and bleeding, although relevant, may not offer as much real-time information about the patient's condition compared to percussion.

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Mrs. D is a pregnant client who is 33 weeks' gestation and is admitted for bright red vaginal bleeding. Her physician suspects placenta previa. All of the following nursing interventions are appropriate for this client except:

  • A. Institute complete bed rest for the client
  • B. Assess uterine tone to determine condition
  • C. Perform a vaginal exam to assess cervical dilation
  • D. Measure and record blood loss each shift
Correct Answer: C

Rationale: A client with placenta previa has part of the placenta covering some or all of the cervical opening. Performing a vaginal exam for placenta previa may cause significant bleeding and should be avoided unless directed by a physician, and preparations are made for emergency delivery. **Choice A** is correct as complete bed rest is essential to decrease the risk of further bleeding. **Choice B** is appropriate as assessing uterine tone helps in determining the condition of the uterus and can provide important information for the healthcare team. **Choice D** is also a necessary intervention as monitoring and recording blood loss is crucial in assessing the client's condition and response to treatment.

The healthcare provider is preparing to use an otoscope for an examination. Which statement is true regarding the otoscope?

  • A. Often used to direct light into the sinuses
  • B. Used to examine the structures of the internal ear
  • C. Uses a short, broad speculum to help visualize the ear
  • D. Directs light into the ear canal and onto the tympanic membrane
Correct Answer: D

Rationale: The otoscope is a tool used to examine the ear canal and tympanic membrane, which separates the external and middle ear. It is not intended to direct light into the sinuses or examine the internal structures of the ear. The otoscope typically uses a short, narrow speculum to aid in visualizing the ear canal and tympanic membrane, not a short, broad speculum as mentioned in choice C.

When examining an older adult, which technique should the nurse use?

  • A. Minimize touching the patient as much as possible.
  • B. Attempt to perform the entire physical examination during one visit.
  • C. Speak loudly and slowly due to potential hearing deficits in aging adults.
  • D. Arrange the sequence of the examination to allow as few position changes as possible.
Correct Answer: D

Rationale: When examining an older adult, it is crucial to arrange the sequence of the examination to minimize position changes. This helps prevent discomfort and fatigue for the older adult, who may have mobility issues. Option A is incorrect because physical touch is essential when examining older adults, as their other senses may be diminished. Option B is incorrect as it is better to break the examination into multiple visits to ensure thoroughness and comfort. Option C is incorrect because while some older adults may have hearing deficits, it is not appropriate to assume this for all individuals without proper assessment.

When caring for children with a different cultural perspective, what challenge may the nurse recognize?

  • A. Children have spiritual needs that are influenced by their stages of development
  • B. Children have spiritual needs that are direct reflections of what is occurring in their homes
  • C. Religious beliefs rarely affect the parents' perceptions of the illness
  • D. Parents are often the decision-makers, and they have no knowledge of their children's spiritual needs
Correct Answer: A

Rationale: When caring for children with different cultural perspectives, nurses should acknowledge that children have spiritual needs that are influenced by their stages of development. This understanding is crucial as children, like adults, have varying spiritual needs based on their age and the religious environment within their family. Recognizing and addressing these spiritual needs is essential for providing holistic care. Choices B, C, and D are incorrect as they do not accurately reflect the influence of children's developmental stages on their spiritual needs and the importance of considering these needs in their care.

During an office visit, the healthcare provider is assessing a patient's skin. What part of the hand and technique would be used to best assess the patient's skin temperature?

  • A. Fingertips
  • B. Dorsal surface of the hand
  • C. Ulnar portion of the hand
  • D. Palmar surface of the hand
Correct Answer: B

Rationale: The correct answer is the dorsal surface of the hand. The dorsa (backs) of the hands and fingers are best for determining temperature because the skin is thinner on the dorsal surfaces than on the palms. Fingertips are best for fine, tactile discrimination and not for assessing skin temperature. The ulnar and palmar surfaces of the hands are not as effective for assessing skin temperature as the dorsal surface because they have thicker skin layers.

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