NCLEX-RN
NCLEX RN Exam Preview Answers
1. During a heritage assessment, which question is most appropriate for the nurse to ask?
- A. "Do you smoke?"?
- B. "What is your religion?"?
- C. "Do you have a history of heart disease?"?
- D. "How many years have you lived in the United States?"?
Correct answer: D
Rationale: During a heritage assessment, it is crucial for the nurse to ask questions related to a person's country of ancestry, years in the United States, cultural practices, beliefs, and values. By asking about the number of years lived in the United States, the nurse can gain insights into the individual's cultural background and heritage. Options B, C, and A are not directly related to assessing heritage. Asking about religion only addresses one aspect of heritage, while smoking history and health history do not provide a comprehensive view of a person's heritage.
2. 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.
3. 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.
4. A 6-month-old infant has been brought to the well-child clinic for a checkup. The infant is currently sleeping. What would the nurse do first when beginning the examination?
- A. Wake the infant before beginning the examination.
- B. Examine the infant's hips before the infant wakes up.
- C. Auscultate the lungs and heart while the infant is still sleeping.
- D. Begin with the assessment of the eye and continue with the remainder of the examination in a head-to-toe approach.
Correct answer: C
Rationale: When the infant is quiet or sleeping, it is an ideal time to assess the cardiac, respiratory, and abdominal systems. It is recommended not to wake the infant unnecessarily. Auscultating the lungs and heart while the infant is still sleeping allows for a comprehensive assessment without disturbing the infant. Examining the infant's hips prematurely may disrupt the infant's sleep. Starting with an assessment of the eye is not appropriate as it is an invasive procedure and should be performed towards the end of the examination after the non-invasive assessments have been completed.
5. The instructor is teaching a class on basic assessment skills. Which of the following statements is true regarding the stethoscope and its use?
- A. Slope of the earpieces should point forward toward the examiner's nose.
- B. It blocks out extraneous room noise but does not magnify sound.
- C. The tubing length should be 14 to 18 inches to prevent sound distortion.
- D. Both fit and quality of the stethoscope are important.
Correct answer: B
Rationale: The stethoscope does not magnify sound but effectively blocks out extraneous room noises. The correct orientation of the earpieces is with the slope pointing forward toward the examiner's nose, not posteriorly. The tubing length of a stethoscope should ideally be between 14 to 18 inches (36 to 46 cm) to avoid sound distortion. Using tubing longer than this range can distort sound. Both the fit and quality of the stethoscope are crucial for accurate auscultation and assessment, highlighting their significance in clinical practice. Therefore, the correct answer is that the stethoscope blocks out extraneous room noise but does not magnify sound.
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