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NCLEX RN Exam Preview Answers
1. When performing a physical assessment, what technique should the nurse always perform first?
- A. Palpation
- B. Inspection
- C. Percussion
- D. Auscultation
Correct answer: Inspection
Rationale: During a physical assessment, the nurse should always begin with inspection. The sequence of techniques for physical examination is inspection, palpation, percussion, and auscultation. These skills are performed in a specific order, except for the abdominal assessment where auscultation precedes palpation and percussion. Inspection allows the nurse to observe and gather initial information without direct contact. It is a crucial step that provides valuable insights before proceeding to palpation, percussion, and auscultation. Therefore, choice B, 'Inspection,' is the correct answer. Choices A, C, and D are incorrect because they should follow inspection in the sequence of a comprehensive physical assessment.
2. What are Korotkoff sounds?
- A. Sounds noted during diastole.
- B. The result of the vibration of blood against artery walls while blood pressure readings are being taken.
- C. Sounds only noted by skilled cardiologists.
- D. Distinct sounds which are classified into 6 phases.
Correct answer: The result of the vibration of blood against artery walls while blood pressure readings are being taken.
Rationale: Korotkoff sounds are the sounds that occur when blood flows in an artery that has been temporarily compressed during a blood pressure measurement. These sounds result from the vibration of blood against the artery walls as the pressure cuff is released. There are five distinct phases of Korotkoff sounds, which healthcare providers are trained to identify during blood pressure assessment. The correct answer, choice B, accurately describes the nature of Korotkoff sounds and how they are generated. Choices A, C, and D are incorrect because Korotkoff sounds are not specific to diastole, not limited to skilled cardiologists, and categorized into five phases, not six.
3. A client is receiving high-dose brachytherapy as a form of cancer treatment. What type of teaching must the nurse include when educating this client about safety?
- A. The client must remain in isolation under airborne precautions
- B. The client should stay in a private room at the hospital
- C. The client may need to limit visits from friends and family
- D. Both B and C
Correct answer: Both B and C
Rationale: A client undergoing high-dose brachytherapy has a radiation implant placed for cancer treatment. To ensure safety, the client should be in a private hospital room to prevent radiation exposure to others. Limiting visits from friends and family is necessary to prevent overexposure. Option A is incorrect as isolation under airborne precautions is not required for brachytherapy. Option B and C are the correct choices as they focus on minimizing radiation exposure to others, ensuring safety during treatment.
4. Which of the following interventions should be prioritized in the care of the suicidal client?
- A. Remove all potentially harmful items from the client’s room
- B. Allow the client to express feelings of hopelessness
- C. Note the client’s capabilities to increase self esteem
- D. Set a “no suicide” contract with the client
Correct answer: Remove all potentially harmful items from the client’s room
Rationale: accessibility of the means of suicide increases the lethality. Allowing a patient to express feelings and setting a no suicide contract are interventions for suicidal client but blocking the means of suicide is priority. Increasing self esteem is an intervention for depressed clients but not specifically for suicide.
5. The nurse cares for a patient who has just had a thoracentesis. Which assessment information obtained by the nurse is a priority to communicate to the health care provider?
- A. Oxygen saturation is 88%.
- B. Blood pressure is 145/90 mm Hg.
- C. Respiratory rate is 22 breaths/minute when lying flat.
- D. Pain level is 5 (on a 0 to 10 scale) with a deep breath.
Correct answer: Oxygen saturation is 88%.
Rationale: The correct answer is 'Oxygen saturation is 88%.' Following a thoracentesis, oxygen saturation should improve. A saturation of 88% suggests a potential complication like pneumothorax. While the other assessment findings are important, the priority is to address the low oxygen saturation to prevent further complications. High blood pressure and respiratory rate may also need attention, but the immediate concern is the oxygen saturation level. Pain level, though significant for the patient's comfort, takes lower priority compared to the potential life-threatening issue of hypoxia.
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