NCLEX NCLEX-RN
NCLEX RN Exam Prep
1. Penny Thornton has had a stroke, or CVA, and is having difficulty eating on her own. Soon, she will be getting some assistive devices for eating meals. Which healthcare worker will be providing Penny with these assistive devices?
- A. A physical therapist
- B. A speech therapist
- C. A social worker
- D. An occupational therapist
Correct answer: An occupational therapist
Rationale: An occupational therapist is the healthcare professional responsible for assessing the needs of individuals, like Penny, regarding assistive devices that aid them in their daily activities. In this case, assistive devices for eating, such as weighted plates and specialized utensils, are crucial for helping Penny regain independence in feeding herself. Physical therapists focus more on mobility and movement, speech therapists on communication and swallowing disorders, and social workers on providing emotional and social support. Therefore, the correct choice is the occupational therapist as they specialize in activities of daily living and promoting independence.
2. A patient experiences a chest wall contusion as a result of being struck in the chest with a baseball bat. The emergency department nurse would be most concerned if which finding is observed during the initial assessment?
- A. Paradoxic chest movement
- B. Complaint of chest wall pain
- C. Heart rate of 110 beats/minute
- D. Large bruised area on the chest
Correct answer: Paradoxic chest movement
Rationale: Paradoxic chest movement is the most concerning finding as it indicates a potential flail chest, which can lead to severe compromise in gas exchange and rapid hypoxemia. This condition requires immediate attention to prevent respiratory distress. Complaint of chest wall pain, a slightly elevated heart rate, and a large bruised area on the chest are important assessment findings but may not immediately threaten gas exchange or respiratory function. Therefore, identifying paradoxic chest movement is critical for prompt intervention and management.
3. The client finds a client crying behind a locked bathroom door. The client will not open the door. Which action should the nurse implement first?
- A. Instruct an unlicensed assistive personnel (UAP) to stay and keep talking to the client.
- B. Sit quietly in the client's room until the client leaves the bathroom.
- C. Allow the client to cry alone and leave the client in the bathroom.
- D. Talk to the client and attempt to find out why the client is crying.
Correct answer: Talk to the client and attempt to find out why the client is crying.
Rationale: The nurse's first concern should be for the client's safety, so an immediate assessment of the client's situation is needed. Option D is the correct choice as it involves directly addressing the client's emotional state and attempting to understand the reason for the distress. In a vulnerable situation like this, the nurse should take the lead in assessing and communicating with the client. Option A is incorrect as it would delegate the responsibility to someone else when the nurse should be the one to initiate the assessment. Option B is inappropriate as it does not actively address the client's emotional needs or safety. Option C is also incorrect because leaving the client alone without further assessment could potentially endanger the client's well-being.
4. According to the American Heart Association standards, high-quality CPR for an adult includes all of the following EXCEPT:
- A. Push hard
- B. Push fast
- C. Allow chest recoil between compressions
- D. Pause CPR as each drug is administered
Correct answer: Pause CPR as each drug is administered
Rationale: High-quality CPR for adults should not be paused for drug administration. The correct CPR technique involves pushing hard and fast, at a rate of at least 100 compressions per minute and to a depth of at least 2 inches. It is also essential to allow chest recoil between compressions to enable proper blood circulation. Pausing CPR for drug administration would delay the delivery of continuous chest compressions, which are crucial for maintaining blood flow and oxygenation during cardiac arrest.
5. The healthcare provider is preparing to perform a physical assessment. Which statement is true about the inspection phase of the physical assessment?
- A. Usually yields little information
- B. Takes time and reveals a surprising amount of information
- C. May be somewhat uncomfortable for the expert practitioner
- D. Requires a thorough examination of the patient's body before proceeding with palpation
Correct answer: Takes time and reveals a surprising amount of information
Rationale: During the inspection phase of a physical assessment, it is essential to take time as it can reveal a significant amount of information. Initially, it may feel uncomfortable for the examiner to focus solely on observing the patient without immediate action. Rushing through inspection is not recommended as it can lead to missing important cues. Train yourself to be thorough during inspection by observing carefully and taking the time needed to gather essential data. Choices A, C, and D are incorrect because inspection typically provides valuable information, may feel uncomfortable at first but is necessary for a comprehensive assessment, and does not involve a quick glance but requires a focused and detailed observation.
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