NCLEX-RN
NCLEX RN Exam Preview Answers
1. An adult patient is at the clinic for a physical examination. The patient states that they are feeling 'very anxious' about the physical examination. What steps can the nurse take to make the patient more comfortable?
- A. Appear unhurried and confident when examining the patient.
- B. Leave the room when the patient undresses unless they need assistance.
- C. Ask the patient to change into an examining gown and to leave their undergarments on.
- D. Measure vital signs at the beginning of the examination to gradually accustom the patient.
Correct answer: A
Rationale: To help alleviate the patient's anxiety, the nurse should appear unhurried and confident during the examination. This can make the patient feel more at ease and reassured. It is important for the nurse to respect the patient's privacy by leaving the room while the patient changes unless assistance is needed. The patient should be instructed to change into an examining gown while leaving their undergarments on, providing a sense of comfort and familiarity. Additionally, measuring vital signs at the beginning of the examination can help gradually acclimate the patient to the process, making it less overwhelming. Therefore, the correct answer is to appear unhurried and confident when examining the patient. Choices B, C, and D are incorrect because they do not directly address the patient's anxiety or provide comfort in the same way as the correct answer.
2. What action by the nurse is appropriate when examining a 16-year-old male teenager?
- A. Discuss health teaching with the teenager to promote wellness.
- B. Ask the parent to step out of the room during the history and physical examination to respect the teenager's privacy.
- C. Use age-appropriate communication when speaking to the teenager to ensure understanding.
- D. Provide feedback that his body is developing normally and discuss the wide variation among teenagers on the rate of growth and development.
Correct answer: D
Rationale: During the examination of a 16-year-old male teenager, it is essential to provide feedback that his body is developing normally and to discuss the wide variation among teenagers regarding growth and development. This reassures the teenager about his health status and addresses any concerns about physical development. It is important to recognize that adolescents are very conscious of their body image and often compare themselves to their peers, hence the need for such feedback. Asking the parent to step out of the room respects the teenager's privacy and promotes open communication between the nurse and the teenager. Using age-appropriate communication is crucial to ensure that the teenager understands the information provided. Asking the parent to stay in the room may not be ideal as it can inhibit open discussion, and talking to the teenager as if they were a younger child is inappropriate and may undermine their autonomy and understanding.
3. 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.
4. While performing the physical examination, why does the nurse share information and briefly teach the patient?
- A. To help the patient feel more comfortable and gain control of the situation
- B. To build rapport and increase the patient's confidence in the examiner
- C. To assist the patient in understanding his or her disease process and treatment modalities
- D. To aid the patient in identifying questions about his or her disease and potential areas of needed education
Correct answer: B
Rationale: Sharing information and briefly teaching the patient during a physical examination helps build rapport and increase the patient's confidence in the examiner. This approach gives the patient a sense of control in a situation that can often be overwhelming. While sharing information may make the patient feel more comfortable, the primary goal is to enhance the patient's confidence in the examiner. Providing information does not necessarily directly assist the patient in understanding their disease process and treatment modalities, as this may require a more in-depth explanation. The main focus is on establishing a trusting relationship and empowering the patient during the examination, rather than solely aiding in identifying questions or areas needing education.
5. 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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