NCLEX-RN
NCLEX RN Exam Preview Answers
1. A 2-year-old child has been brought to the clinic for a well-child checkup. What is the best way for the nurse to begin the assessment?
- A. Ask the parent to place the child on the examining table.
- B. Have the parent remove all of the child's clothing before the examination.
- C. Allow the child to keep a security object such as a toy or blanket during the examination.
- D. Initially focus the interactions on the child, essentially ignoring the parent until the child's trust has been obtained.
Correct answer: C
Rationale: The best place to examine the toddler is on the parent's lap. Toddlers understand symbols; therefore, a security object is helpful. Initially, the focus is more on the parent, which allows the child to adjust gradually and to become familiar with you. A 2-year-old child does not like to take off his or her clothes. Therefore, ask the parent to undress one body part at a time.
2. When performing a physical assessment, what technique should the nurse always perform first?
- A. Palpation
- B. Inspection
- C. Percussion
- D. Auscultation
Correct answer: B
Rationale: During a physical assessment, the nurse should always begin with inspection. The sequence of techniques for physical examination is inspection, palpation, percussion, and auscultation. These skills are performed in a specific order, except for the abdominal assessment where auscultation precedes palpation and percussion. Inspection allows the nurse to observe and gather initial information without direct contact. It is a crucial step that provides valuable insights before proceeding to palpation, percussion, and auscultation. Therefore, choice B, 'Inspection,' is the correct answer. Choices A, C, and D are incorrect because they should follow inspection in the sequence of a comprehensive physical assessment.
3. In which situation would the nurse use bimanual palpation technique?
- A. Palpating the thorax of an infant
- B. Palpating the kidneys and uterus
- C. Assessing pulsations and vibrations
- D. Assessing the presence of tenderness and pain
Correct answer: B
Rationale: Bimanual palpation involves using both hands to envelop or capture specific body parts or organs like the kidneys, uterus, or adnexa. This technique is particularly useful for assessing the size, shape, consistency, and mobility of deep organs like the kidneys and uterus. Palpating the thorax of an infant (Choice A) is usually done with a different technique like gentle, single-handed palpation. Assessing pulsations and vibrations (Choice C) and assessing tenderness and pain (Choice D) typically do not require the use of bimanual palpation, making Choices A, C, and D incorrect.
4. After receiving change-of-shift report, which patient should the nurse assess first?
- A. A patient with pneumonia who has crackles in the right lung base
- B. A patient with possible lung cancer who has just returned after bronchoscopy
- C. A patient with hemoptysis and a 16-mm induration with tuberculin skin testing
- D. A patient with chronic obstructive pulmonary disease (COPD) and pulmonary function testing (PFT) that indicates low forced vital capacity
Correct answer: B
Rationale: The correct answer is the patient with possible lung cancer who has just returned after bronchoscopy. After bronchoscopy, the patient may have decreased cough and gag reflexes, necessitating immediate assessment for airway patency to prevent potential complications. The other patients do not exhibit urgent clinical manifestations or have undergone recent procedures that require immediate attention. Therefore, they can be assessed after ensuring the safety and stability of the patient who has just returned after bronchoscopy.
5. An examiner is using an ophthalmoscope to examine a patient's eyes. The patient has astigmatism and is nearsighted. Which of these techniques by the examiner would indicate that the examination is being correctly performed?
- A. Rotating the lens selector dial to bring the object into focus
- B. Using the large full circle of light when assessing pupils that are not dilated
- C. Rotating the lens selector dial to the black numbers to compensate for astigmatism
- D. Using the grid on the lens aperture dial to visualize the external structures of the eye
Correct answer: A
Rationale: To correctly perform an eye examination using an ophthalmoscope on a patient with astigmatism and nearsightedness, the examiner should rotate the lens selector dial to bring the object into focus. This adjustment helps compensate for nearsightedness or farsightedness but does not correct astigmatism. Rotating the lens selector dial to the black numbers is not an appropriate technique for compensating for astigmatism. Using the grid on the lens aperture dial is primarily for visualizing external structures of the eye, not for addressing refractive errors. The large full circle of light is typically used when assessing dilated pupils, not for examining patients with astigmatism and nearsightedness. Therefore, the correct technique is rotating the lens selector dial to bring the object into focus.
Similar Questions
Access More Features
NCLEX RN Basic
$69.99/ 30 days
- 5,000 Questions with answers
- Comprehensive NCLEX coverage
- 30 days access @ $69.99
NCLEX RN Premium
$149.99/ 90 days
- 5,000 Questions with answers
- Comprehensive NCLEX coverage
- 30 days access @ $149.99