NCLEX-RN
NCLEX RN Exam Preview Answers
1. 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.
2. During an assessment, the nurse notices that a patient is handling a small charm that is tied to a leather strip around their neck. Which action by the nurse is appropriate?
- A. Ask the patient about the item and its significance.
- B. Ask the patient to lock the item with other valuables in the hospital's safe.
- C. Tell the patient that a family member should take valuables home.
- D. No action is necessary.
Correct answer: A
Rationale: The small charm tied to a leather strip is likely an amulet, which many cultures consider an important means of protection from 'evil spirits.' When a patient appears to have a health practice the nurse is unfamiliar with, the nurse should ask for clarification in a non-judgmental way that communicates acceptance of their beliefs and allows for open communication. Thus, the nurse in this situation should inquire about the amulet's meaning to the patient. Asking the patient to lock the item with other valuables in the hospital's safe, telling the patient that a family member should take valuables home, or doing nothing does not address the importance or meaning of a cultural health practice to the patient and does not allow the nurse to gain an understanding of the patient's cultural health practices.
3. A patient has suddenly developed shortness of breath and appears to be in significant respiratory distress. After calling the physician and placing the patient on oxygen, which of these actions is the best for the nurse to take when further assessing the patient?
- A. Count the patient's respirations.
- B. Bilaterally percuss the thorax, noting any differences in percussion tones.
- C. Call for a chest x-ray and wait for the results before beginning an assessment.
- D. Inspect the thorax for any new masses and bleeding associated with respirations.
Correct answer: B
Rationale: In a situation where a patient is in significant respiratory distress, bilaterally percussing the thorax to note any differences in percussion tones is a crucial nursing intervention. Percussion provides instant feedback regarding changes in underlying tissue density, which can give important clues about the patient's physical status. This hands-on assessment technique is readily available and can be performed promptly. Counting the patient's respirations, while important, may not provide as much detailed information as percussion. Ordering a chest x-ray and waiting for the results can cause a delay in assessing and addressing the patient's immediate needs. Inspecting the thorax for new masses and bleeding, although relevant, may not offer as much real-time information about the patient's condition compared to percussion.
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 nurse is discussing the term subculture with a student nurse. Which statement by the nurse would best describe subculture?
- A. "Fitting as many people as possible into the majority culture."?
- B. "Identifying small groups of people who do not want to be identified with the larger culture."?
- C. "Singling out groups of people who suffer differential and unequal treatment as a result of cultural variations."?
- D. "Recognizing groups of people within a culture with shared characteristics that are not common to all members of the culture."?
Correct answer: D
Rationale: A subculture refers to a group of people within a larger culture who share distinct beliefs, values, or attitudes that are not universal among all members of the larger culture. Subcultures can emerge based on factors such as ethnicity, religion, education, occupation, age, and gender. The correct answer describes the concept of a subculture accurately. Choices A, B, and C are incorrect because they do not capture the essence of a subculture. Fitting people into the majority culture, identifying small groups who distance themselves from the larger culture, or singling out individuals facing differential treatment do not define subculture. Subcultures represent specific groups with shared characteristics that differentiate them from the broader cultural norms.
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