NCLEX-RN
NCLEX RN Exam Preview Answers
1. The nurse is preparing to perform a physical assessment. The correct action by the nurse is reflected by which statement?
- A. Performs the examination from both sides of the bed.
- B. Examines tender or painful areas last to help relieve the patient's anxiety.
- C. Follows a flexible examination sequence, considering the patient's age and condition.
- D. Organizes the assessment to ensure that the patient does not change positions too often.
Correct answer: D
Rationale: The nurse should organize the assessment to minimize the patient's need to change positions frequently, ensuring efficiency and comfort. It is essential to perform the examination from both sides of the bed to facilitate a comprehensive assessment. Examining tender or painful areas last can help reduce patient discomfort and anxiety. The examination sequence should be flexible, taking into account the patient's age, condition, and specific needs. This approach allows for a tailored and patient-centered assessment, optimizing the quality of care provided.
2. The nurse is examining a 2-year-old child and asks, "May I listen to your heart now?"? Which critique of the nurse's technique is most accurate?
- A. Asking questions may enhance the child's autonomy.
- B. Asking the child for permission helps develop a sense of trust.
- C. This question is an inappropriate statement because children at this age like to have choices.
- D. Children at this age like to say, "No."? The examiner should not offer a choice when no choice is available.
Correct answer: D
Rationale: Children at the age of 2 often like to assert their independence by saying "No."? In situations where there is actually no choice available, offering a false choice can lead to a lack of trust. It is important not to offer a choice when there isn't one, as doing so may undermine trust. While asking for permission can enhance autonomy and trust, offering a limited option like, "Shall I listen to your heart next or your tummy?"? may be a better approach. Therefore, the correct critique of the nurse's technique in this scenario is that children at this age tend to say "No,"? so the examiner should avoid offering a choice when there isn't a real alternative.
3. When planning a cultural assessment, what component should the nurse include?
- A. Family history
- B. Chief complaint
- C. Medical history
- D. Health practices
Correct answer: D
Rationale: When conducting a cultural assessment, it is essential to include the patient's health practices. Health practices encompass the beliefs, values, and behaviors related to health and illness within a specific cultural context. These practices provide insight into how individuals perceive and manage their health. Family history, chief complaint, and medical history are crucial components of a patient's overall assessment but do not directly relate to a cultural assessment. Focusing on health practices allows the nurse to better understand the patient's cultural background and tailor care to meet their specific needs.
4. During a class on cultural practices, the nurse hears the term cultural taboo. Which statement illustrates the concept of a cultural taboo?
- A. Trying prayer before seeking medical help
- B. Believing that illness is a punishment of sin
- C. Refusing to accept blood products as part of treatment
- D. Stating that a child's birth defect is the result of the parents' sins
Correct answer: C
Rationale: The concept of a cultural taboo involves practices that are forbidden or avoided within a particular culture. Refusing to accept blood products as part of treatment is a clear example of a cultural taboo, as some cultures or religions prohibit the use of blood products for medical purposes. This practice is deeply rooted in cultural beliefs and traditions. The other choices provided do not directly relate to cultural taboos. Trying prayer before seeking medical help, believing illness is a punishment of sin, and stating that a child's birth defect is the result of parents' sins are beliefs or actions based on religious or personal beliefs, but they do not specifically represent cultural taboos.
5. After receiving change-of-shift report, which patient should the nurse assess first?
- A. A patient with pneumonia who has crackles in the right lung base
- B. A patient with possible lung cancer who has just returned after bronchoscopy
- C. A patient with hemoptysis and a 16-mm induration with tuberculin skin testing
- D. A patient with chronic obstructive pulmonary disease (COPD) and pulmonary function testing (PFT) that indicates low forced vital capacity
Correct answer: B
Rationale: The correct answer is the patient with possible lung cancer who has just returned after bronchoscopy. After bronchoscopy, the patient may have decreased cough and gag reflexes, necessitating immediate assessment for airway patency to prevent potential complications. The other patients do not exhibit urgent clinical manifestations or have undergone recent procedures that require immediate attention. Therefore, they can be assessed after ensuring the safety and stability of the patient who has just returned after bronchoscopy.
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