NCLEX-RN
NCLEX RN Exam Preview Answers
1. When caring for children with a different cultural perspective, what challenge may the nurse recognize?
- A. Children have spiritual needs that are influenced by their stages of development
- B. Children have spiritual needs that are direct reflections of what is occurring in their homes
- C. Religious beliefs rarely affect the parents' perceptions of the illness
- D. Parents are often the decision-makers, and they have no knowledge of their children's spiritual needs
Correct answer: A
Rationale: When caring for children with different cultural perspectives, nurses should acknowledge that children have spiritual needs that are influenced by their stages of development. This understanding is crucial as children, like adults, have varying spiritual needs based on their age and the religious environment within their family. Recognizing and addressing these spiritual needs is essential for providing holistic care. Choices B, C, and D are incorrect as they do not accurately reflect the influence of children's developmental stages on their spiritual needs and the importance of considering these needs in their care.
2. When measuring a patient's body temperature, what factor should be considered that can influence the temperature?
- A. Constipation
- B. Diurnal cycle
- C. Nocturnal cycle
- D. Patient's emotional state
Correct answer: B
Rationale: When measuring body temperature, it is essential to consider factors that can influence it. The diurnal cycle, which refers to the body's natural temperature variations throughout a 24-hour period, can impact body temperature readings. Factors like exercise, age, and environment can also affect body temperature. Constipation does not directly influence body temperature. The 'nocturnal cycle' is not a recognized term in relation to body temperature. While a patient's emotional state can affect vital signs, it is not a primary factor in influencing body temperature measurements.
3. When examining an older adult, which technique should the nurse use?
- A. Minimize touching the patient as much as possible.
- B. Attempt to perform the entire physical examination during one visit.
- C. Speak loudly and slowly due to potential hearing deficits in aging adults.
- D. Arrange the sequence of the examination to allow as few position changes as possible.
Correct answer: D
Rationale: When examining an older adult, it is crucial to arrange the sequence of the examination to minimize position changes. This helps prevent discomfort and fatigue for the older adult, who may have mobility issues. Option A is incorrect because physical touch is essential when examining older adults, as their other senses may be diminished. Option B is incorrect as it is better to break the examination into multiple visits to ensure thoroughness and comfort. Option C is incorrect because while some older adults may have hearing deficits, it is not appropriate to assume this for all individuals without proper assessment.
4. Which of the following is one of the three smallest bones in the body?
- A. Vomer
- B. Distal phalanx of the small toe
- C. Stapes
- D. Coccyx
Correct answer: C
Rationale: The stapes, along with the malleus and incus, are the three smallest bones in the human body. These bones are located in the inner ear and play a crucial role in hearing. The vomer is a bone in the nasal cavity and is not one of the smallest bones. The distal phalanx of the small toe is relatively larger and not among the smallest bones. The coccyx, also known as the tailbone, is not one of the smallest bones in the body.
5. When providing mouth care to a patient in a coma, what should you do to provide good and safe mouth care?
- A. keep the head of the bed up to prevent aspiration
- B. brush the teeth and rinse the mouth with a cup of water
- C. use a special foam swab to brush only the tongue
- D. use a special foam swab to brush the tongue and teeth
Correct answer: D
Rationale: When providing mouth care to a patient in a coma, it is crucial to use a special foam swab to brush the tongue and teeth. This method helps maintain good oral hygiene for comatose patients. Special foam swabs are designed to effectively clean all areas of the mouth, including the cheeks and tongue, ensuring thorough care. Using water for mouth care in comatose patients can lead to aspiration, so it is important to avoid this practice. Keeping the head of the bed up alone does not prevent aspiration during mouth care for comatose patients, making choice A incorrect. Merely brushing the tongue (choice C) or using a foam swab only on the tongue (choice B) may not provide the comprehensive mouth care necessary for patients in a coma.
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