NCLEX-RN
NCLEX RN Exam Preview Answers
1. A woman who has lived in the United States for a year after moving from Europe has learned to speak English and is almost finished with her college studies. She now dresses like her peers and says that her family in Europe would hardly recognize her. This situation illustrates which concept?
- A. Integration
- B. Assimilation
- C. Biculturalism
- D. Heritage consistency
Correct answer: B
Rationale: Assimilation is a unidirectional, linear process moving from unacculturated to acculturated, in which a person develops a new cultural identity and becomes like members of the dominant culture. In this scenario, the woman has adapted to the new culture by learning the language, dressing like her peers, and expressing that her family in Europe would hardly recognize her. This aligns with the process of assimilation. Integration and biculturalism, on the other hand, involve bidirectional and bidimensional processes that induce reciprocal change in both cultures while maintaining aspects of the original culture in one's ethnic identity. Since there is no indication in the question that the woman has retained aspects of her original culture, integration and biculturalism are not the correct concepts. Heritage consistency refers to the degree to which one retains their original or traditional culture, which is not addressed in the scenario provided.
2. Which of the following is an anthropometric measurement?
- A. Blood pressure
- B. Temperature
- C. Pulse Rate
- D. Weight
Correct answer: D
Rationale: Anthropometric measurements relate to the size, weight, and proportions of the human body. Weight is a key anthropometric measurement as it directly reflects body mass, making it the correct choice. Blood pressure, temperature, and pulse rate are physiological measurements that do not specifically pertain to body size or proportion, hence making them incorrect choices in the context of anthropometric measurements.
3. A 4-month-old child is at the clinic for a well-baby checkup and immunizations. Which of these actions is most appropriate when the nurse is assessing an infant's vital signs?
- A. The infant's radial pulse should be palpated, and the nurse should notice any fluctuations resulting from activity or exercise.
- B. The nurse should auscultate an apical rate for 1 minute and then assess for any normal irregularities, such as sinus dysrhythmia.
- C. The infant's blood pressure should be assessed by using a stethoscope with a large diaphragm piece to hear the soft muffled Korotkoff sounds.
- D. The infant's chest should be observed and the respiratory rate counted for 1 minute; the respiratory pattern may vary significantly.
Correct answer: B
Rationale: The nurse auscultates an apical rate, not a radial pulse, with infants and toddlers. The pulse should be counted by listening to the heart for 1 full minute to account for normal irregularities, such as sinus dysrhythmia. Children younger than 3 years of age have such small arm vessels; consequently, hearing Korotkoff sounds with a stethoscope is difficult. The nurse should use either an electronic blood pressure device that uses oscillometry or a Doppler ultrasound device to amplify the sounds. An infant's respiratory rate should be assessed by observing the infant's abdomen, not chest, because an infant's respirations are normally more diaphragmatic than thoracic. The nurse should auscultate an apical heart rate, not palpate a radial pulse, with infants and toddlers.
4. Which statement by the client with chronic obstructive lung disease indicates an understanding of the major reason for the use of occasional pursed-lip breathing?
- A. ''This action of my lips helps to keep my airway open.''
- B. ''I can expel more air when I pucker up my lips to breathe out.''
- C. ''My mouth doesn't get as dry when I breathe with pursed lips.''
- D. ''By prolonging breathing out with pursed lips, the smaller areas in my lungs don't collapse.''
Correct answer: D
Rationale: The correct answer is D. Clients with chronic obstructive pulmonary disease have difficulty exhaling fully due to the weak alveolar walls from the disease process. Pursed-lip breathing helps prevent alveolar collapse by maintaining positive pressure in the airways during exhalation. This is the major reason for using pursed-lip breathing in individuals with chronic obstructive lung disease. Choices A, B, and C are incorrect because they do not directly address the main purpose of pursed-lip breathing, which is to prevent alveolar collapse and improve exhalation in these patients.
5. What is the most useful patient position for proctologic exams?
- A. Trendelenburg
- B. Semi-Fowler's
- C. Full Fowler's
- D. Jack Knife
Correct answer: D
Rationale: The Jack Knife position is the most useful for proctologic exams as it allows the patient to lie face down while keeping the buttocks elevated, providing optimal access for the examination. The Trendelenburg position, characterized by the body being laid flat with the feet higher than the head, is not suitable for proctologic exams. Semi-Fowler's and Full Fowler's positions are typically utilized for respiratory or cardiovascular conditions and are not ideal for proctologic examinations due to their lack of optimal access to the perianal area.
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