NCLEX-RN
NCLEX RN Exam Preview Answers
1. During an assessment, the nurse notices that a patient is handling a small charm that is tied to a leather strip around their neck. Which action by the nurse is appropriate?
- A. Ask the patient about the item and its significance.
- B. Ask the patient to lock the item with other valuables in the hospital's safe.
- C. Tell the patient that a family member should take valuables home.
- D. No action is necessary.
Correct answer: A
Rationale: The small charm tied to a leather strip is likely an amulet, which many cultures consider an important means of protection from 'evil spirits.' When a patient appears to have a health practice the nurse is unfamiliar with, the nurse should ask for clarification in a non-judgmental way that communicates acceptance of their beliefs and allows for open communication. Thus, the nurse in this situation should inquire about the amulet's meaning to the patient. Asking the patient to lock the item with other valuables in the hospital's safe, telling the patient that a family member should take valuables home, or doing nothing does not address the importance or meaning of a cultural health practice to the patient and does not allow the nurse to gain an understanding of the patient's cultural health practices.
2. When percussing over the lungs of a 4-year-old child, the nurse hears bilateral loud, long, and low tones. How should the nurse proceed?
- A. Palpate over the area for increased pain and tenderness.
- B. Ask the child to take shallow breaths and percuss over the area again.
- C. Refer the child to a specialist because of an increased amount of air in the lungs.
- D. Consider this finding as normal for a child this age and proceed with the examination.
Correct answer: D
Rationale: In pediatric patients, loud, long, and low tones heard when percussing over the lungs are normal findings. These percussion notes are characteristic of a child's lung due to its thin chest wall and increased air content. It is unnecessary to palpate for pain and tenderness, ask the child to take shallow breaths and repeat the percussion, or refer the child to a specialist. Therefore, the correct action is to consider these findings as normal for the child's age and continue with the examination.
3. During an examination of a patient's abdomen, the nurse notes that the abdomen is rounded and firm to the touch. During percussion, the nurse notes a drum-like quality of the sounds across the quadrants. How would the nurse interpret this type of sound?
- A. Constipation
- B. Air-filled areas
- C. Presence of a tumor
- D. Presence of dense organs
Correct answer: B
Rationale: A musical or drum-like sound (tympany) is heard when percussion occurs over an air-filled viscus, such as the stomach or intestines. This indicates the presence of air-filled areas. Constipation, choice A, does not produce specific percussion sounds and is related to bowel movements rather than the sound produced during percussion. The presence of a tumor, choice C, would not typically produce a drum-like sound but might result in dullness or decreased resonance. Dense organs, choice D, would produce a dull thud sound rather than a drum-like tympanic sound.
4. What should the nurse anticipate or expect of an American Indian woman seeking help to regulate her diabetes?
- A. Will comply with the treatment prescribed.
- B. Has given up her belief in naturalistic causes of disease.
- C. May also be seeking the assistance of a shaman or medicine man.
- D. Will need extra help in dealing with her illness and may be experiencing a crisis of faith.
Correct answer: C
Rationale: When caring for an American Indian patient seeking help for diabetes, the nurse should anticipate that the patient may also seek the assistance of a shaman or medicine man in addition to biomedical treatment. This cultural practice is common among American Indians who believe in holistic healing involving body, mind, and spirit. It is important for the nurse to acknowledge and respect these cultural beliefs and practices. Choice A is incorrect because patients from different cultures may not always comply with prescribed treatments due to various factors, including cultural beliefs. Choice B is incorrect as patients seeking traditional healing methods do not necessarily give up their beliefs in naturalistic causes of disease; instead, they often complement biomedical care. Choice D is incorrect as assuming the patient is experiencing a crisis of faith is not appropriate; it is more about respecting and understanding the patient's cultural background and beliefs.
5. What is the most important step that healthcare personnel can take to prevent the transmission of microorganisms in the hospital setting?
- A. Wear protective eyewear at all times.
- B. Wear gloves whenever in direct contact with patients.
- C. Wash hands before and after contact with each patient.
- D. Clean the stethoscope with an alcohol swab between patients.
Correct answer: C
Rationale: The most crucial step in preventing the transmission of microorganisms in the hospital setting is proper hand hygiene. Healthcare personnel should wash their hands thoroughly before and after each patient contact to reduce the risk of spreading infections. While cleaning the stethoscope with an alcohol swab between patients is recommended, it is secondary to hand hygiene. Wearing protective eyewear at all times is not necessary for routine patient care unless specifically indicated, and wearing gloves only when in direct contact with patients is important but not as critical as proper handwashing. Therefore, the correct answer is to wash hands before and after contact with each patient.
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