NCLEX-RN
NCLEX RN Exam Preview Answers
1. After receiving change-of-shift report, which patient should the nurse assess first?
- A. A patient with pneumonia who has crackles in the right lung base
- B. A patient with possible lung cancer who has just returned after bronchoscopy
- C. A patient with hemoptysis and a 16-mm induration with tuberculin skin testing
- D. A patient with chronic obstructive pulmonary disease (COPD) and pulmonary function testing (PFT) that indicates low forced vital capacity
Correct answer: B
Rationale: The correct answer is the patient with possible lung cancer who has just returned after bronchoscopy. After bronchoscopy, the patient may have decreased cough and gag reflexes, necessitating immediate assessment for airway patency to prevent potential complications. The other patients do not exhibit urgent clinical manifestations or have undergone recent procedures that require immediate attention. Therefore, they can be assessed after ensuring the safety and stability of the patient who has just returned after bronchoscopy.
2. When examining an older adult, which technique should the nurse use?
- A. Minimize touching the patient as much as possible.
- B. Attempt to perform the entire physical examination during one visit.
- C. Speak loudly and slowly due to potential hearing deficits in aging adults.
- D. Arrange the sequence of the examination to allow as few position changes as possible.
Correct answer: D
Rationale: When examining an older adult, it is crucial to arrange the sequence of the examination to minimize position changes. This helps prevent discomfort and fatigue for the older adult, who may have mobility issues. Option A is incorrect because physical touch is essential when examining older adults, as their other senses may be diminished. Option B is incorrect as it is better to break the examination into multiple visits to ensure thoroughness and comfort. Option C is incorrect because while some older adults may have hearing deficits, it is not appropriate to assume this for all individuals without proper assessment.
3. Which of these statements is true regarding the use of Standard Precautions in the healthcare setting?
- A. Standard Precautions apply to all body fluids, except sweat.
- B. Alcohol-based hand rub should be used if hands are not visibly dirty.
- C. Standard Precautions are intended for use with all patients, regardless of their risk or presumed infection status.
- D. Standard Precautions are to be used only when non-intact skin, excretions containing visible blood, or expected contact with mucous membranes are present.
Correct answer: C
Rationale: Standard Precautions are designed to reduce the risk for transmission of microorganisms from both recognized and unrecognized sources. They are intended for use with all patients, regardless of their risk or presumed infection status. Standard Precautions apply to all body fluids, secretions, and excretions except sweat - whether or not they contain visible blood, non-intact skin, or mucous membranes. Hands should be washed with soap and water if visibly soiled with blood or body fluids. Alcohol-based hand rubs can be used if hands are not visibly soiled. Choice A is incorrect because Standard Precautions apply to all body fluids, secretions, and excretions except sweat. Choice B is incorrect because alcohol-based hand rub should be used when hands are not visibly dirty. Choice D is incorrect because Standard Precautions are not limited to situations involving non-intact skin, excretions with visible blood, or expected mucous membrane contact.
4. While auscultating heart sounds, the nurse hears a murmur. Which of these instruments would be used to assess this murmur?
- A. Electrocardiogram
- B. Bell of the stethoscope
- C. Diaphragm of the stethoscope
- D. Palpation with the nurse's palm of the hand
Correct answer: B
Rationale: The correct instrument to assess a murmur while auscultating heart sounds is the bell of the stethoscope. An electrocardiogram is used to measure the heart's electrical activity, not to assess murmurs. Palpation with the nurse's palm of the hand is a method to assess pulses or textures, not heart murmurs. The diaphragm of the stethoscope is typically used for high-pitched sounds like breath, bowel, and normal heart sounds, whereas the bell is more suitable for soft, low-pitched sounds such as murmurs or extra heart sounds.
5. Which theory reflects the view that illness is caused by an imbalance or disharmony in the forces of nature?
- A. Germ theory
- B. Naturalistic theory
- C. Magicoreligious theory
- D. Biomedical or scientific theory
Correct answer: B
Rationale: The naturalistic theory posits that illness results from an imbalance or disharmony in the forces of nature. According to this theory, maintaining a natural balance or harmony is essential to prevent illness. Conversely, germ theory and biomedical or scientific theory attribute illness to microorganisms, while magicoreligious theory attributes illness to supernatural forces such as deities or spirits. Therefore, the most appropriate theory reflecting the belief that illness arises from a disruption in natural forces is the naturalistic theory.
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