NCLEX-RN
NCLEX RN Exam Preview Answers
1. When examining an infant, which area should the nurse examine first?
- A. Ear
- B. Nose
- C. Throat
- D. Abdomen
Correct answer: D
Rationale: When examining an infant, the nurse should start by examining the least-distressing areas first before moving on to more invasive areas. The abdomen is typically the least distressing area to examine, so it should be assessed first. Examining the eye, ear, nose, and throat are considered more invasive and should be saved for last. Therefore, the correct choice is to examine the abdomen first to ensure a comfortable and less distressing examination process for the infant. Choices A, B, and C (Ear, Nose, Throat) are more invasive areas and should be examined after the abdomen.
2. When teaching a patient to use the three-point gait technique of crutch use:
- A. The injured leg moves ahead at the same time as both crutches.
- B. One crutch moves at a time and is then followed by the injured leg.
- C. Both crutches move ahead at the same time followed by both legs at the same time.
- D. None of the above are correct.
Correct answer: A
Rationale: The correct technique for a three-point gait involves the injured leg moving simultaneously with both crutches, followed by the uninjured leg. This gait pattern is utilized when the patient is unable to bear full weight on one of their legs. Choice A accurately describes the appropriate sequence of movements for the three-point gait technique. Choices B and C do not accurately reflect the correct pattern of movement during the three-point gait technique, making them incorrect. Choice D is incorrect as there is a correct option among the choices provided.
3. During an assessment, a nurse asks a patient, "If you had fever and vomiting for 3 days, what would you do?"? Which aspect of the mental status examination is the nurse assessing?
- A. Behavior
- B. Cognition
- C. Affect and mood
- D. Perceptual disturbances
Correct answer: B
Rationale: The nurse is assessing cognition in this scenario. Cognition involves evaluating a patient's judgment and decision-making abilities. By asking the patient what they would do in a specific situation, the nurse aims to determine the patient's cognitive function. A correct response indicating intact cognition would involve a decision like 'Call my doctor.' If the patient suggests inappropriate actions like 'I would stop eating' or 'I would just wait and see what happened,' it would suggest impaired judgment. The other options, behavior, affect and mood, and perceptual disturbances, refer to different aspects of the mental status examination and are not directly assessed through this question.
4. What is the primary purpose of emergency planning?
- A. Comply with the laws of the state.
- B. Comply with the laws of the U.S.
- C. Comply with both state and U.S. laws
- D. Maintain safety
Correct answer: D
Rationale: The primary purpose of emergency planning is to ensure and maintain the safety of people and the preservation of objects, such as buildings and personal possessions during emergencies or disasters. While compliance with state and federal laws regarding emergency planning is important, the main goal is to prioritize life and safety. Choices A, B, and C focus on legal compliance, which is necessary but secondary to the fundamental objective of safeguarding lives and property in emergency situations.
5. The Sinoatrial Node (SA) is located within which of the following heart structures?
- A. Mitral Valve
- B. Right Ventricle
- C. Right Atrium
- D. Left Atrium
Correct answer: C
Rationale: The Sinoatrial (SA) Node, often called the heart's natural pacemaker, is situated within the upper wall of the Right Atrium. It initiates the electrical impulses that regulate the heartbeat. Choices A, B, and D are incorrect because the SA node is not located in the Mitral Valve, Right Ventricle, or Left Atrium. It is specifically positioned in the Right Atrium to coordinate the heart's rhythm and timing.
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