NCLEX-RN
NCLEX RN Exam Preview Answers
1. When preparing to perform a physical examination on an infant, what should the nurse do?
- A. Have the parent remove all clothing except the diaper.
- B. Instruct the parent not to feed the infant immediately before the examination.
- C. Allow the infant to suck on a pacifier during abdominal auscultation.
- D. Ensure the parent is present during the examination.
Correct answer: A
Rationale: For performing a physical examination on an infant, it is important to have the parent remove all clothing except the diaper to allow for a thorough examination while ensuring the infant remains comfortable. It is recommended not to feed the infant immediately before the examination but rather 1 to 2 hours after feeding when the baby is neither too drowsy nor too hungry. While a pacifier may be used during invasive assessments or if the infant is crying, it is not typically necessary during abdominal auscultation. Having the parent present during the examination is important for the infant's security and for the parent to understand the process; however, the clothing should still be removed except for the diaper to facilitate a comprehensive assessment.
2. The healthcare professional is preparing to percuss the abdomen of a patient. What characteristic of the underlying tissue does percussion assess?
- A. Turgor
- B. Texture
- C. Density
- D. Consistency
Correct answer: C
Rationale: Percussion is a technique used to assess the density of underlying organs by producing sounds that help determine their location and size. Turgor, texture, and consistency are primarily assessed through palpation, not percussion. Turgor refers to skin elasticity, texture pertains to the feel of the tissue surface, and consistency relates to the firmness or resistance of the tissue.
3. 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.
4. While percussing over the liver of a patient, the nurse notices a dull sound. What should the nurse do?
- A. Consider this a normal finding
- B. Palpate this area for an underlying mass
- C. Reposition the hands and attempt to percuss in this area again
- D. Consider this finding as abnormal and refer the patient for additional treatment
Correct answer: A
Rationale: When percussing over relatively dense organs, such as the liver or spleen, a dull sound is a normal finding due to the organ's density. This occurs because the sound waves produced by tapping on the organ travel through the dense tissue, resulting in a dull sound. Therefore, the correct action for the nurse in this scenario is to consider a dull sound over the liver as a normal finding. Palpating for an underlying mass (Choice B) is not indicated based on the percussion finding alone. Repositioning the hands and repeating the percussion (Choice C) may not change the dull sound over the liver. Referring the patient for additional treatment (Choice D) without understanding the normal percussion findings over the liver would be premature. Thus, the most appropriate action is to interpret the dull sound as a normal finding.
5. 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.
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