NCLEX-RN
NCLEX RN Exam Preview Answers
1. The healthcare provider is preparing to perform a physical assessment. Which statement is true about the inspection phase of the physical assessment?
- A. Usually yields little information
- B. Takes time and reveals a surprising amount of information
- C. May be somewhat uncomfortable for the expert practitioner
- D. Requires a thorough examination of the patient's body before proceeding with palpation
Correct answer: B
Rationale: During the inspection phase of a physical assessment, it is essential to take time as it can reveal a significant amount of information. Initially, it may feel uncomfortable for the examiner to focus solely on observing the patient without immediate action. Rushing through inspection is not recommended as it can lead to missing important cues. Train yourself to be thorough during inspection by observing carefully and taking the time needed to gather essential data. Choices A, C, and D are incorrect because inspection typically provides valuable information, may feel uncomfortable at first but is necessary for a comprehensive assessment, and does not involve a quick glance but requires a focused and detailed observation.
2. When providing mouth care to a patient in a coma, what should you do to provide good and safe mouth care?
- A. keep the head of the bed up to prevent aspiration
- B. brush the teeth and rinse the mouth with a cup of water
- C. use a special foam swab to brush only the tongue
- D. use a special foam swab to brush the tongue and teeth
Correct answer: D
Rationale: When providing mouth care to a patient in a coma, it is crucial to use a special foam swab to brush the tongue and teeth. This method helps maintain good oral hygiene for comatose patients. Special foam swabs are designed to effectively clean all areas of the mouth, including the cheeks and tongue, ensuring thorough care. Using water for mouth care in comatose patients can lead to aspiration, so it is important to avoid this practice. Keeping the head of the bed up alone does not prevent aspiration during mouth care for comatose patients, making choice A incorrect. Merely brushing the tongue (choice C) or using a foam swab only on the tongue (choice B) may not provide the comprehensive mouth care necessary for patients in a coma.
3. For the nursing diagnostic statement, Self-care deficit: feeding related to bilateral fractured wrists in casts, what is the major related factor or risk factor identified by the nurse?
- A. Discomfort
- B. Deficit
- C. Feeding
- D. Fractured wrists
Correct answer: D
Rationale: The correct answer is 'Fractured wrists.' In a nursing diagnostic statement, the related factor or risk factor is the underlying cause of the identified problem. In this case, the major factor affecting the self-care deficit in feeding is the bilateral fractured wrists in casts. The fractured wrists directly impact the client's ability to feed themselves, making it the primary related factor. Choices A, B, and C are incorrect as discomfort, deficit, and feeding are not the primary cause of the feeding problem in this scenario; rather, it is the physical limitation caused by the fractured wrists that is the focus of the nursing intervention.
4. A client with an enlarged prostate is having trouble starting his flow of urine when using the bathroom. Another name for this condition is:
- A. Hesitancy
- B. Oliguria
- C. Retention
- D. Urgency
Correct answer: A
Rationale: Urinary hesitancy occurs when a client has difficulty starting a flow of urine while using the bathroom. Hesitancy may be due to physiological factors, such as obstruction from an enlarged prostate, or due to psychological factors, such as anxiety or embarrassment. Oliguria refers to decreased urine output, retention is the inability to empty the bladder fully, and urgency is the sudden and strong need to urinate.
5. During a class on religion and spirituality, the nurse is asked to define spirituality. Which statement by the nurse best describes spirituality?
- A. "Is a personal search to discover a supreme being."?
- B. "Is an organized system of beliefs concerning the cause, nature, and purpose of the universe."?
- C. "Is a belief that each person exists forever in some form, such as a belief in reincarnation or the afterlife."?
- D. "Focuses on a connection with something bigger than oneself and a belief in transcendence."?
Correct answer: D
Rationale: Spirituality is a broad term that focuses on a connection with something greater than oneself and a belief in transcendence. It is a personal journey that arises from unique life experiences and the individual's quest to find purpose and meaning in life. The correct answer emphasizes the essence of spirituality, which involves seeking a connection with a higher power and believing in transcendence. Choices A, B, and C, on the other hand, define aspects of religion rather than spirituality. Choice A refers to a personal search for a supreme being, which is more aligned with religious beliefs. Choice B describes an organized system of beliefs about the universe, typically associated with religion. Choice C pertains to beliefs about existence after death, such as reincarnation or the afterlife, which are often religious concepts. Therefore, the best description of spirituality is focusing on a connection with something beyond oneself and a belief in transcendence.
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