NCLEX-RN
NCLEX RN Exam Preview Answers
1. 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.
2. Which of the following is part of client teaching regarding antiembolism stockings?
- A. Instruct the client to roll the top portion of the stocking down if it is too long
- B. Stockings are applied with the toes uncovered at the end
- C. Measure for thigh-high stockings from the foot to the knee
- D. Stockings are to be smooth from end to end without wrinkles
Correct answer: D
Rationale: When educating clients about antiembolism stockings, it is essential to emphasize that the stockings should be smooth from end to end without wrinkles. Wrinkles in the stockings can impede circulation, defeating the purpose of wearing them to prevent blood clot formation. Instructing the client to roll the top portion of the stocking down if it is too long (Choice A) is incorrect as it can create unnecessary pressure points. Stockings should be applied with the toes covered at the end (Choice B) to ensure proper compression. Measuring for thigh-high stockings should be done from the knee to the foot (Choice C) to ensure the correct fit and compression gradient.
3. A client with expressive aphasia is pointing wildly at the bath water but unable to speak. Which response from the nurse is most appropriate?
- A. Is something wrong with the bath water?
- B. Just calm down, we'll finish your bath soon.
- C. Are you trying to tell me something?
- D. Shall I turn on the television?
Correct answer: A
Rationale: A client with expressive aphasia faces difficulty expressing themselves verbally but can understand others. In this scenario, the client's gestures indicate a communication attempt. The nurse's best response is to directly address the potential issue the client is indicating, which is the bath water. Option A acknowledges the client's non-verbal communication and seeks to address their concern. Choices B, C, and D do not directly address the client's attempt to communicate about the bath water, which is the focal point of the interaction.
4. 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.
5. The healthcare provider is examining a patient who is reporting "feeling cold."? Which is a mechanism of heat loss in the body?
- A. Exercise
- B. Radiation
- C. Metabolism
- D. Food digestion
Correct answer: B
Rationale: When the body needs to lose heat, one of the mechanisms it employs is radiation. Radiation involves the transfer of heat from the body to the environment in the form of infrared waves. While metabolism, exercise, and food digestion contribute to heat production, they are not mechanisms for heat loss. Metabolism generates heat as a byproduct, exercise increases metabolic rate leading to heat production, and food digestion involves some heat generation, but these processes do not directly facilitate heat loss. Therefore, in the scenario where the patient is feeling cold, radiation is the primary mechanism for the body to lose excess heat and maintain a stable internal temperature.
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