the nurse is reviewing percussion techniques with a new graduate nurse which action performed by the graduate nurse while percussing requires the nurs
Logo

Nursing Elites

NCLEX-RN

NCLEX RN Exam Preview Answers

1. The nurse is reviewing percussion techniques with a new graduate nurse. Which action performed by the graduate nurse while percussing requires the nurse to intervene?

Correct answer: A

Rationale: The correct answer is to percuss twice over each area, not once. This technique helps ensure a more accurate assessment. Striking with the fingertip instead of the finger pad is correct because the tip of the finger produces clearer sounds. Using the wrist to make the strikes instead of the arm is appropriate as it allows for more controlled and precise percussion. Quickly lifting the striking finger after each stroke is also correct to prevent damping off vibrations. Therefore, percussing once over each area (Choice A) is incorrect as it does not follow the standard percussion technique.

2. Which of the following is a negative outcome associated with impaired mobility?

Correct answer: B

Rationale: A client with impaired mobility may develop changes in body systems that put them at risk of further illness or injury. One negative outcome associated with impaired mobility is orthostatic hypotension, where blood pressure drops significantly when moving from a sitting or lying position to a standing position. This drop in blood pressure can lead to symptoms such as dizziness or fainting. This occurs because blood circulates more slowly or pools in the distal extremities due to impaired mobility. Choice A is incorrect because increased calcium absorption is not a typical negative outcome associated with impaired mobility. Choice C is incorrect because a decrease in mucus in the bronchi and lungs is not a common negative outcome of impaired mobility. Choice D is incorrect because thickening of vessel walls in the circulatory system is not directly associated with impaired mobility.

3. The client often sighs and says in a monotone voice, 'I'm never going to get over this.' When encouraged to participate in care, the client says, 'I don't have the energy.' These cues are suggestive of which nursing diagnoses? Select all that apply.

Correct answer: A

Rationale: A nursing diagnosis involves clinical judgment about a response to a health problem. In this scenario, the client's expressions of feeling overwhelmed and lacking energy indicate feelings of hopelessness and powerlessness. While fatigue is mentioned, there is no direct evidence to support an interrupted sleep pattern, making option C incorrect. Similarly, disturbed self-esteem and self-care deficit are not evident from the given cues, making options D and E incorrect.

4. Nursing care plans contain which of the following?

Correct answer: A

Rationale: Nursing care plans are legal documents that contain nursing diagnoses, such as an "Alteration of respiratory function". They also contain patient goals and nursing interventions.

5. Improper placement of the hands under the rib cage when performing the Heimlich maneuver could result in:

Correct answer: B

Rationale: The xiphoid process is a small, cartilaginous extension at the inferior end of the sternum. Placing the hands improperly during the Heimlich maneuver too close to this process can result in it breaking off and potentially causing damage to internal organs. Choices A and C are incorrect because the manubrium of the sternum and the coccyx are not in the area where the hands would typically be placed during the Heimlich maneuver.

Similar Questions

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?
Which of the following descriptors is most appropriate to use when stating the 'problem' part of a nursing diagnosis?
Which of these guidelines would a healthcare professional follow when measuring a patient's weight?
A urine pregnancy test:
To collect timely, specific information, the nurse is most likely to ask which of the following questions?

Access More Features

NCLEX RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access

NCLEX RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access

Other Courses