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. 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.
3. While explaining an illness to a 10-year-old, what should the nurse keep in mind about the cognitive development at this age?
- A. They are able to make simple associations of ideas
- B. They are able to think logically in organizing facts
- C. Interpretation of events originates from their own perspective
- D. Conclusions are based on previous experiences
Correct answer: B
Rationale: At the age of 10, children are in the concrete operations stage according to Piaget. They are capable of mature thought when allowed to manipulate and organize objects. This means they can think logically, organize facts, and understand cause-and-effect relationships. Choices A, C, and D are incorrect. While simple associations of ideas may occur, the key cognitive ability at this stage is the capacity for logical thought and organization of information. Interpretation of events from their own perspective is more characteristic of younger children, and conclusions based on previous experiences are more aligned with older children or adults.
4. A client is preparing to irrigate a colostomy. Which of the following situations is a contraindication for this type of irrigation?
- A. The client has an incontinent ostomy
- B. The client has an irregular bowel routine
- C. The client has diverticulitis
- D. The colostomy bag contains fecal material
Correct answer: C
Rationale: When a client with a colostomy is preparing for irrigation, it is essential to consider contraindications that could pose risks or worsen the client's condition. Diverticulitis is a contraindication for colostomy irrigation because the inflamed diverticula could be further irritated by the flushing action during irrigation, potentially leading to complications. An incontinent ostomy, irregular bowel routine, or presence of fecal material in the colostomy bag are not specific contraindications for irrigation and can be managed through appropriate techniques and interventions.
5. The nurse should wash from the ________________________ when washing a patient's eye area.
- A. outer canthus to the inner canthus
- B. inner canthus to the outer canthus
- C. internal nares to the external nares
- D. external nares to the internal nares
Correct answer: B
Rationale: When washing a patient's eye area, it is important to start from the inner canthus (closest to the nose) and move towards the outer canthus. This direction prevents any contaminants or debris from the outer area of the eye from moving towards the inner, more sensitive area. Choices C and D are incorrect as they pertain to the nasal passages (nares), which are not relevant when washing the eye area.
Similar Questions
Access More Features
NCLEX RN Basic
$69.99/ 30 days
- 5,000 Questions with answers
- Comprehensive NCLEX coverage
- 30 days access
NCLEX RN Premium
$149.99/ 90 days
- 5,000 Questions with answers
- Comprehensive NCLEX coverage
- 30 days access