NCLEX-RN
NCLEX RN Exam Preview Answers
1. When preparing to perform a physical examination on an infant, what should the nurse do?
- A. Have the parent remove all clothing except the diaper.
- B. Instruct the parent not to feed the infant immediately before the examination.
- C. Allow the infant to suck on a pacifier during abdominal auscultation.
- D. Ensure the parent is present during the examination.
Correct answer: A
Rationale: For performing a physical examination on an infant, it is important to have the parent remove all clothing except the diaper to allow for a thorough examination while ensuring the infant remains comfortable. It is recommended not to feed the infant immediately before the examination but rather 1 to 2 hours after feeding when the baby is neither too drowsy nor too hungry. While a pacifier may be used during invasive assessments or if the infant is crying, it is not typically necessary during abdominal auscultation. Having the parent present during the examination is important for the infant's security and for the parent to understand the process; however, the clothing should still be removed except for the diaper to facilitate a comprehensive assessment.
2. Who is legally able to make decisions for the patient or resident during a patient care conference when the patient is not mentally able to make decisions on their own?
- A. The patient or their healthcare proxy
- B. Only the patient
- C. Only the healthcare proxy
- D. The doctor
Correct answer: C
Rationale: When a patient is unable to make decisions due to mental incapacity, the healthcare proxy, designated by the patient in advance, has the legal authority to make decisions on the patient's behalf. In this situation, the patient lacks the capacity to make decisions independently. The healthcare proxy's role is to represent the patient's wishes and best interests. The doctor's role in a patient care conference is to provide medical expertise, offer recommendations, and assist in the decision-making process, but the final decision-making authority lies with the healthcare proxy, not the doctor.
3. What is the MOST ACCURATE statement regarding the ESR test?
- A. The results are diagnostic for certain conditions.
- B. Abnormal results are indicative of a potentially fatal illness.
- C. Abnormal results should be followed by additional testing.
- D. Results are reported in millimeters per hour.
Correct answer: C
Rationale: The erythrocyte sedimentation rate (ESR) is a non-specific screening test for inflammation in the body. It is not used as a definitive diagnostic tool for specific conditions. When ESR results are abnormal, they indicate the presence of inflammation, which can be caused by various reasons. Therefore, abnormal results should be followed by additional testing to determine the underlying cause. The ESR test measures the rate at which red blood cells settle in a vertical tube over the span of one hour, and results are reported in millimeters per hour. Choice A is incorrect because ESR results are not solely diagnostic for any specific condition. Choice B is incorrect as abnormal ESR results do not directly indicate a potentially fatal illness without further investigation. Choice D is incorrect as the results are reported in millimeters per hour, not per minute.
4. 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.
5. Patients have a right to ______________.
- A. only enough information so they can comply with care
- B. ALL of their health-related information
- C. small amounts of information so they do not get nervous
- D. moderate amounts of information unless they are old
Correct answer: B
Rationale: Patients have a legal right to access all of their health-related information. This includes details about their health condition, treatment options, test results, and any other relevant data. Providing patients with all their health-related information empowers them to make informed decisions about their care, promotes transparency in the healthcare process, and respects their autonomy. Choices A, C, and D are incorrect because they restrict the information patients should receive based on assumptions or limitations, which goes against the principle of patient autonomy and their right to access their complete health-related information.
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