NCLEX-RN
NCLEX RN Exam Preview Answers
1. The nurse is preparing to examine a 4-year-old child. Which action by the nurse is appropriate for this age group?
- A. Explain the procedures briefly to alleviate the child's anxiety.
- B. Give the child feedback and reassurance during the examination.
- C. Ask the child to undress as needed for the examination.
- D. Perform an examination of the head last.
Correct answer: B
Rationale: For a 4-year-old child, short and simple explanations should be provided to avoid overwhelming the child. It is important to give feedback and reassurance during the examination to create a comforting environment for the child. Asking the child to undress as needed is appropriate for a thorough examination, as children at this age are usually willing to do so. Performing an examination of the head last allows the child to become more comfortable during the assessment. Therefore, the most appropriate action for a 4-year-old child is to provide feedback and reassurance during the examination, ensuring a positive experience for the child.
2. The healthcare professional is preparing to use a stethoscope for auscultation. Which statement is true regarding the diaphragm of the stethoscope?
- A. Used to listen for high-pitched sounds
- B. Used to listen for low-pitched sounds
- C. Should be firmly held against the person's skin to block out low-pitched sounds
- D. Should be lightly held against the person's skin to listen for extra heart sounds and murmurs
Correct answer: A
Rationale: The diaphragm of the stethoscope is designed for listening to high-pitched sounds like breath, bowel, and normal heart sounds. It should be firmly held against the person's skin to ensure optimal sound transmission, leaving a ring after use. On the other hand, the bell of the stethoscope is ideal for detecting soft, low-pitched sounds such as extra heart sounds or murmurs. Therefore, the diaphragm is not used to block out low-pitched sounds but rather to enhance the detection of high-frequency sounds.
3. Mrs. D is a pregnant client who is 33 weeks' gestation and is admitted for bright red vaginal bleeding. Her physician suspects placenta previa. All of the following nursing interventions are appropriate for this client except:
- A. Institute complete bed rest for the client
- B. Assess uterine tone to determine condition
- C. Perform a vaginal exam to assess cervical dilation
- D. Measure and record blood loss each shift
Correct answer: C
Rationale: A client with placenta previa has part of the placenta covering some or all of the cervical opening. Performing a vaginal exam for placenta previa may cause significant bleeding and should be avoided unless directed by a physician, and preparations are made for emergency delivery. **Choice A** is correct as complete bed rest is essential to decrease the risk of further bleeding. **Choice B** is appropriate as assessing uterine tone helps in determining the condition of the uterus and can provide important information for the healthcare team. **Choice D** is also a necessary intervention as monitoring and recording blood loss is crucial in assessing the client's condition and response to treatment.
4. The nurse supervises unlicensed assistive personnel (UAP) who are providing care for a patient with right lower lobe pneumonia. The nurse should intervene if which action by UAP is observed?
- A. UAP splint the patient's chest during coughing.
- B. UAP assist the patient to ambulate to the bathroom.
- C. UAP help the patient to a bedside chair for meals.
- D. UAP lower the head of the patient's bed to 15 degrees.
Correct answer: D
Rationale: The correct action for the nurse to intervene in is when the UAP lowers the head of the patient's bed to 15 degrees. This position can decrease ventilation in a patient with pneumonia, potentially worsening their condition. Choices B and C involve assisting the patient with activities of daily living and promoting mobility, which are appropriate for the patient's care. Choice A, splinting the patient's chest during coughing, can help the patient manage coughing effectively, which is also appropriate for a patient with pneumonia.
5. The healthcare provider is reviewing theories of illness. The germ theory, which states that microscopic organisms such as bacteria and viruses are responsible for specific disease conditions, is a basic belief of which theory of illness?
- A. Holistic
- B. Biomedical
- C. Naturalistic
- D. Magicoreligious
Correct answer: B
Rationale: The correct answer is B: Biomedical. Among the biomedical explanations for disease is the germ theory, which states that microscopic organisms such as bacteria and viruses are responsible for specific disease conditions. The naturalistic or holistic perspective holds that the forces of nature must be kept in natural balance. The magicoreligious perspective holds that supernatural forces dominate and cause illness or health. Therefore, options A, C, and D are incorrect as they do not align with the germ theory explanation provided in the question.
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