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NCLEX RN Exam Preview Answers
1. While percussing over the liver of a patient, the nurse notices a dull sound. What should the nurse do?
- A. Consider this a normal finding
- B. Palpate this area for an underlying mass
- C. Reposition the hands and attempt to percuss in this area again
- D. Consider this finding as abnormal and refer the patient for additional treatment
Correct answer: Consider this a normal finding
Rationale: When percussing over relatively dense organs, such as the liver or spleen, a dull sound is a normal finding due to the organ's density. This occurs because the sound waves produced by tapping on the organ travel through the dense tissue, resulting in a dull sound. Therefore, the correct action for the nurse in this scenario is to consider a dull sound over the liver as a normal finding. Palpating for an underlying mass (Choice B) is not indicated based on the percussion finding alone. Repositioning the hands and repeating the percussion (Choice C) may not change the dull sound over the liver. Referring the patient for additional treatment (Choice D) without understanding the normal percussion findings over the liver would be premature. Thus, the most appropriate action is to interpret the dull sound as a normal finding.
2. When assessing a patient who has just arrived after an automobile accident, the emergency department nurse notes tachycardia and absent breath sounds over the right lung. For which intervention will the nurse prepare the patient?
- A. Emergency pericardiocentesis
- B. Stabilization of the chest wall with tape
- C. Administration of an inhaled bronchodilator
- D. Insertion of a chest tube with a chest drainage system
Correct answer: Insertion of a chest tube with a chest drainage system
Rationale: The patient's history and absent breath sounds suggest a right-sided pneumothorax or hemothorax, which will require treatment with a chest tube and drainage. Emergency pericardiocentesis is not indicated as the patient's symptoms are not suggestive of cardiac tamponade. Stabilization of the chest wall with tape would not address the underlying issue of a potential pneumothorax or hemothorax. Administration of an inhaled bronchodilator is not appropriate in this scenario as the patient is not exhibiting signs of asthma or bronchoconstriction. Therefore, the correct intervention for this patient is the insertion of a chest tube with a chest drainage system to address the potential pneumothorax or hemothorax.
3. The UAP who has just been accepted to nursing school says to a client, 'You must be so pleased with your progress.' The nurse later explains to the UAP that this is an example of what type of question?
- A. Close-ended question
- B. Open-ended question
- C. Leading question
- D. Neutral question
Correct answer: Leading question
Rationale: The statement 'You must be so pleased with your progress' is an example of a leading question. Leading questions guide the respondent towards a particular answer or response, potentially biasing the data collected. In this scenario, the UAP's question implies that the client should be pleased with their progress, steering the client's response. Closed-ended questions typically elicit brief factual responses or a 'yes' or 'no.' Open-ended questions encourage clients to provide detailed responses and share their thoughts and feelings freely. Neutral questions do not lead or influence the client's response, allowing for unbiased information gathering.
4. The client is being educated about depression by the nurse. Which statement by the client indicates that the teaching has been effective?
- A. ''All elderly individuals experience depression occasionally.''
- B. ''I'm relieved that I will improve within 2 or 3 days.''
- C. ''I never realized depression could occur without a specific cause.''
- D. ''Reducing stress in my life will alleviate the depression.''
Correct answer: ''I never realized depression could occur without a specific cause.''
Rationale: The correct answer, 'I never realized depression could occur without a specific cause,' demonstrates an understanding that depression can arise without a clear trigger, indicating effective teaching. Choice A is incorrect because not all elderly individuals experience depression, and this statement doesn't show understanding. Choice B is incorrect as it reflects a misconception about the quick resolution of depression. Choice D is incorrect as it oversimplifies the relationship between stress reduction and depression resolution.
5. A patient is diagnosed with both human immunodeficiency virus (HIV) and active tuberculosis (TB) disease. Which information obtained by the nurse is most important to communicate to the healthcare provider?
- A. The Mantoux test induration measured 7 mm.
- B. The chest x-ray revealed infiltrates in the lower lobes.
- C. The patient is receiving antiretroviral therapy for HIV infection.
- D. The patient has a cough producing blood-tinged mucus.
Correct answer: The patient is receiving antiretroviral therapy for HIV infection.
Rationale: The most critical information to communicate to the healthcare provider in a patient diagnosed with both HIV and active TB disease is that the patient is receiving antiretroviral therapy for HIV infection. This is crucial because drug interactions can occur between antiretrovirals used to treat HIV infection and medications used to treat TB. By informing the healthcare provider about the antiretroviral therapy, potential interactions can be assessed and managed effectively to optimize patient care. The other data provided, such as the Mantoux test result, chest x-ray findings, and presence of blood-tinged mucus, are important clinical information but are expected in a patient with coexisting HIV and TB and do not directly impact potential drug interactions between antiretrovirals and TB medications.
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