NCLEX-RN
NCLEX RN Exam Preview Answers
1. 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.
2. Which technique of assessment will the healthcare provider use to determine the presence of crepitus, swelling, and pulsations?
- A. Palpation
- B. Inspection
- C. Percussion
- D. Auscultation
Correct answer: A
Rationale: Palpation involves using the sense of touch to assess various characteristics such as texture, temperature, moisture, organ location and size, as well as detecting swelling, pulsations, vibrations, rigidity, crepitus, lumps, masses, and tenderness or pain. In this scenario, the healthcare provider would utilize palpation to physically feel for crepitus, swelling, and pulsations. Inspection primarily relies on visual assessment, percussion involves assessing through palpable vibrations and audible sounds, and auscultation uses the sense of hearing. Therefore, the correct answer is palpation for assessing the presence of crepitus, swelling, and pulsations.
3. When measuring the vital signs of a 6-month-old infant, which action by the nurse is correct?
- A. Respirations are measured first, followed by pulse and temperature.
- B. Vital signs should be measured as frequently as in an adult.
- C. Procedures are explained to the parent, and the infant is encouraged to handle the equipment.
- D. The nurse should first measure the infant's vital signs before performing a physical examination.
Correct answer: A
Rationale: When assessing vital signs in a 6-month-old infant, the correct order is to measure respirations first, followed by pulse and temperature. This sequence is important to avoid potential alterations in respiratory and pulse rates caused by factors like crying or discomfort. Measuring the temperature first, especially rectally, may lead to an increase in respiratory and pulse rates, which can skew the results. It is crucial to follow this specific order to obtain accurate baseline values. Therefore, option A is the correct choice. Option B is incorrect as the frequency of measuring vital signs in infants differs based on individual needs rather than being consistently more frequent than in adults. Option C is not directly related to the correct sequence for measuring vital signs in infants. Option D is incorrect because the physical examination typically follows the assessment of vital signs in clinical practice.
4. Cheryl M. has a serious swallowing disorder. She has asked you for a glass of water. The doctor has ordered honey thickness liquids for her. Water is not a honey thickness liquid. It is much thinner. What should you do?
- A. Tell the resident that she cannot have water.
- B. Give her applesauce instead of the water.
- C. Tell Cheryl that she is NPO until midnight.
- D. Thicken the water and give it to her.
Correct answer: D
Rationale: You can give Cheryl the water that she has requested; however, since water is not a honey-thick liquid as ordered by the doctor, you must thicken it with a commercial thickener before giving it to her. This will ensure that the water is at the appropriate consistency for her swallowing disorder. Choices A, B, and C are incorrect: A) Telling the resident she cannot have water is not the best course of action without attempting to modify it first. B) Giving her applesauce instead of water does not address the specific request for water. C) Placing Cheryl on NPO status until midnight is unnecessary and does not address her immediate request for water.
5. Who should be members of a patient care conference?
- A. Doctors, nurses, and nursing assistants since they are healthcare providers
- B. Doctors, nurses, and the patient and/or the family members
- C. ALL members of the healthcare team
- D. ALL members of the healthcare team and the patient/resident
Correct answer: D
Rationale: In a patient care conference, it is essential to have all members of the healthcare team present to ensure comprehensive and coordinated care. Including the patient or resident, along with their family members if desired, is crucial as they are the focus of care. Choice A is incorrect because it excludes other important members of the healthcare team. Choice B is partially correct as it includes the patient and/or family members but does not encompass the entire healthcare team. Choice C is too broad and does not specifically address the inclusion of the patient or resident. The correct answer, Choice D, includes all healthcare team members and the patient/resident, ensuring a holistic approach to patient-centered care.
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