NCLEX-RN
NCLEX RN Exam Preview Answers
1. 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.
2. 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.
3. When examining an infant, which area should the nurse examine first?
- A. Ear
- B. Nose
- C. Throat
- D. Abdomen
Correct answer: D
Rationale: When examining an infant, the nurse should start by examining the least-distressing areas first before moving on to more invasive areas. The abdomen is typically the least distressing area to examine, so it should be assessed first. Examining the eye, ear, nose, and throat are considered more invasive and should be saved for last. Therefore, the correct choice is to examine the abdomen first to ensure a comfortable and less distressing examination process for the infant. Choices A, B, and C (Ear, Nose, Throat) are more invasive areas and should be examined after the abdomen.
4. When percussing over the abdomen of an obese patient, the nurse is unable to identify any changes in sound. What would the nurse do next?
- A. Ask the patient to take deep breaths to relax the abdominal musculature.
- B. Consider this finding as normal and proceed with the abdominal assessment.
- C. Increase the amount of strength used when attempting to percuss over the abdomen.
- D. Decrease the amount of strength used when attempting to percuss over the abdomen.
Correct answer: C
Rationale: When percussing an obese patient's abdomen, the thickness of their body wall can affect the sound produced. A stronger percussion stroke is needed for obese or very muscular patients. The force of the blow determines the loudness of the note. Asking the patient to take deep breaths, considering the finding as normal, or decreasing the strength used are not appropriate actions in this scenario.
5. The nurse is preparing to perform a physical assessment. The correct action by the nurse is reflected by which statement?
- A. Performs the examination from both sides of the bed.
- B. Examines tender or painful areas last to help relieve the patient's anxiety.
- C. Follows a flexible examination sequence, considering the patient's age and condition.
- D. Organizes the assessment to ensure that the patient does not change positions too often.
Correct answer: D
Rationale: The nurse should organize the assessment to minimize the patient's need to change positions frequently, ensuring efficiency and comfort. It is essential to perform the examination from both sides of the bed to facilitate a comprehensive assessment. Examining tender or painful areas last can help reduce patient discomfort and anxiety. The examination sequence should be flexible, taking into account the patient's age, condition, and specific needs. This approach allows for a tailored and patient-centered assessment, optimizing the quality of care provided.
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