NCLEX-RN
NCLEX RN Exam Preview Answers
1. During an office visit, the healthcare provider is assessing a patient's skin. What part of the hand and technique would be used to best assess the patient's skin temperature?
- A. Fingertips
- B. Dorsal surface of the hand
- C. Ulnar portion of the hand
- D. Palmar surface of the hand
Correct answer: B
Rationale: The correct answer is the dorsal surface of the hand. The dorsa (backs) of the hands and fingers are best for determining temperature because the skin is thinner on the dorsal surfaces than on the palms. Fingertips are best for fine, tactile discrimination and not for assessing skin temperature. The ulnar and palmar surfaces of the hands are not as effective for assessing skin temperature as the dorsal surface because they have thicker skin layers.
2. Your patient had a stroke, or CVA, five years ago. The resident still has right-sided weakness. You are ready to transfer the resident from the bed to the wheelchair. The wheelchair should be positioned at the _____________.
- A. head of the bed on the patient's right side
- B. head of the bed on the patient's left side
- C. bottom of the bed on the patient's right side
- D. bottom of the bed on the patient's left side
Correct answer: B
Rationale: The wheelchair should be positioned at the head of the bed on the resident's left side. This positioning allows the resident to use their stronger left side to assist with the transfer, compensating for the right-sided weakness. Placing the wheelchair at the head of the bed on the patient's right side (Choice A) would not utilize the stronger left side, which is crucial for the transfer. Similarly, positioning the wheelchair at the bottom of the bed on either side (Choices C and D) would not facilitate optimal assistance from the resident's stronger side during the transfer process.
3. When would chest thrusts be performed in an emergency situation?
- A. When performing CPR to initiate cardiovascular circulation.
- B. When assessing responsiveness of an unconscious patient.
- C. When assisting a pregnant woman who is choking.
- D. None of the above examples indicate the need for chest thrusts.
Correct answer: C
Rationale: In the scenario of an emergency where a pregnant woman is choking, chest thrusts are performed to clear the airway obstruction. This technique is used instead of abdominal thrusts to avoid potential harm to the fetus. While chest thrusts are not as effective as abdominal thrusts in clearing obstructions, they are the preferred method in this specific situation. Choices A and B are incorrect as chest thrusts are not typically performed during CPR to initiate cardiovascular circulation or when assessing responsiveness of an unconscious patient. Choice D is incorrect as chest thrusts are indeed warranted when assisting a pregnant woman who is choking.
4. A patient has come to the office for a blood draw. The patient starts to sweat and is very anxious. Which of the following would be the BEST way to proceed?
- A. Do not perform the procedure. Notify the physician of the reason why.
- B. Perform the procedure but pay close attention for signs of potential syncope.
- C. Allow the patient to reschedule for a time when he isn't as anxious.
- D. Have the physician draw the blood.
Correct answer: B
Rationale: In the scenario where a patient is sweating and anxious, it is important to assess for signs of potential syncope (fainting) while proceeding with the blood draw. If the patient does not exhibit signs of fainting, the phlebotomy procedure can be performed safely. Postponing the procedure may not address the patient's anxiety and inconvenience them. Having the physician draw the blood is not necessary if the phlebotomist can handle the situation effectively.
5. The acronym FAST is used to help responders remember the steps to recognizing which of the following conditions?
- A. Onset of labor in a pregnant woman
- B. Stroke
- C. Heart attack
- D. Migraine
Correct answer: B
Rationale: The correct answer is B: Stroke. The acronym FAST is used to help recognize the signs of a stroke. The letters stand for Face, Arms, Speech, and Time. This mnemonic helps in identifying facial drooping, arm weakness, speech difficulties, and the importance of time in seeking emergency care. Choices A, C, and D are incorrect because the FAST acronym specifically pertains to stroke recognition, not the onset of labor, heart attacks, or migraines.
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