NCLEX-RN
NCLEX RN Exam Preview Answers
1. The healthcare professional is preparing to use a stethoscope for auscultation. Which statement is true regarding the diaphragm of the stethoscope?
- A. Used to listen for high-pitched sounds
- B. Used to listen for low-pitched sounds
- C. Should be firmly held against the person's skin to block out low-pitched sounds
- D. Should be lightly held against the person's skin to listen for extra heart sounds and murmurs
Correct answer: A
Rationale: The diaphragm of the stethoscope is designed for listening to high-pitched sounds like breath, bowel, and normal heart sounds. It should be firmly held against the person's skin to ensure optimal sound transmission, leaving a ring after use. On the other hand, the bell of the stethoscope is ideal for detecting soft, low-pitched sounds such as extra heart sounds or murmurs. Therefore, the diaphragm is not used to block out low-pitched sounds but rather to enhance the detection of high-frequency sounds.
2. Which of the following sets of word parts means 'Pain'?
- A. dynia and -algia
- B. a- and an
- C. ia and -ac
- D. pathy and -osis
Correct answer: A
Rationale: The correct answer is 'dynia and -algia.' The word parts 'dynia' and '-algia' specifically relate to pain. 'Dynia' refers to pain, and '-algia' also denotes pain. Therefore, when combined, they form the meaning 'pain.' Choices B, C, and D are incorrect because 'a-' and 'an' do not relate to pain, 'ia' and '-ac' do not specifically convey pain, and 'pathy' and '-osis' are not word parts that directly signify pain.
3. A patient is in the office for a cyst removal and is very anxious about the procedure. Which of the following descriptions of his respirations would be expected?
- A. Bradypnea
- B. Orthopnea
- C. Tachypnea
- D. Dyspnea
Correct answer: C
Rationale: Tachypnea is defined as a rapid, quick, and shallow respiration rate. When a patient is anxious, they may hyperventilate, leading to tachypnea. Bradypnea (Choice A) is slow breathing, which is not expected in an anxious patient. Orthopnea (Choice B) is difficulty breathing while lying down and is not directly related to anxiety. Dyspnea (Choice D) is shortness of breath, which may not be the primary respiratory pattern seen in an anxious patient undergoing a procedure. Therefore, the correct choice is tachypnea as it aligns with the expected respiratory response to anxiety.
4. An adult patient is at the clinic for a physical examination. The patient states that they are feeling 'very anxious' about the physical examination. What steps can the nurse take to make the patient more comfortable?
- A. Appear unhurried and confident when examining the patient.
- B. Leave the room when the patient undresses unless they need assistance.
- C. Ask the patient to change into an examining gown and to leave their undergarments on.
- D. Measure vital signs at the beginning of the examination to gradually accustom the patient.
Correct answer: A
Rationale: To help alleviate the patient's anxiety, the nurse should appear unhurried and confident during the examination. This can make the patient feel more at ease and reassured. It is important for the nurse to respect the patient's privacy by leaving the room while the patient changes unless assistance is needed. The patient should be instructed to change into an examining gown while leaving their undergarments on, providing a sense of comfort and familiarity. Additionally, measuring vital signs at the beginning of the examination can help gradually acclimate the patient to the process, making it less overwhelming. Therefore, the correct answer is to appear unhurried and confident when examining the patient. Choices B, C, and D are incorrect because they do not directly address the patient's anxiety or provide comfort in the same way as the correct answer.
5. Which nursing intervention is the highest priority for a client at risk for falls in a hospital setting?
- A. Keep all of the side rails up
- B. Review prescribed medications
- C. Complete the "get up and go"? test
- D. Place the bed in the lowest position
Correct answer: D
Rationale: The highest priority nursing intervention for a client at risk for falls in a hospital setting is to place the bed in the lowest position. This action ensures that the client falls the shortest distance, reducing the risk of injury. Keeping all side rails up (Option A) may lead to a fall with injury, as the client might attempt to get over the rail and fall from a higher distance. Reviewing prescribed medications (Option B) is important as certain medications can increase the risk of falling, but it is not the best answer as it is not applicable to all clients. Completing the "get up and go"? test (Option C) can help assess a client's risk for falling but does not directly prevent injury.
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