NCLEX RN Exam Preview Answers

Question 1 of 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.

Question 2 of 5

During an office visit, the healthcare provider is assessing a patient's skin. What part of the hand and technique would be used to best assess the patient's skin temperature?

A. Fingertips B. Dorsal surface of the hand C. Ulnar portion of the hand D. Palmar surface of the hand

Correct Answer: B

Rationale: The correct answer is the dorsal surface of the hand. The dorsa (backs) of the hands and fingers are best for determining temperature because the skin is thinner on the dorsal surfaces than on the palms. Fingertips are best for fine, tactile discrimination and not for assessing skin temperature. The ulnar and palmar surfaces of the hands are not as effective for assessing skin temperature as the dorsal surface because they have thicker skin layers.

Question 3 of 5

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.

Question 4 of 5

After change-of-shift report, which patient should the nurse assess first?

A. 72-year-old with cor pulmonale who has 4+ bilateral edema in his legs and feet B. 28-year-old with a history of a lung transplant and a temperature of 101 F (38.3 C) C. 40-year-old with a pleural effusion who is complaining of severe stabbing chest pain D. 64-year-old with lung cancer and tracheal deviation after subclavian catheter insertion

Correct Answer: D

Rationale: The patient with lung cancer and tracheal deviation after a subclavian catheter insertion should be assessed first. Tracheal deviation can indicate tension pneumothorax, a life-threatening condition that requires immediate intervention to prevent inadequate cardiac output or hypoxemia. While the other patients also need assessment, the potential for tension pneumothorax in the patient with tracheal deviation necessitates urgent attention to prevent complications.

Question 5 of 5

While auscultating heart sounds, the nurse hears a murmur. Which of these instruments would be used to assess this murmur?

A. Electrocardiogram B. Bell of the stethoscope C. Diaphragm of the stethoscope D. Palpation with the nurse's palm of the hand

Correct Answer: B

Rationale: The correct instrument to assess a murmur while auscultating heart sounds is the bell of the stethoscope. An electrocardiogram is used to measure the heart's electrical activity, not to assess murmurs. Palpation with the nurse's palm of the hand is a method to assess pulses or textures, not heart murmurs. The diaphragm of the stethoscope is typically used for high-pitched sounds like breath, bowel, and normal heart sounds, whereas the bell is more suitable for soft, low-pitched sounds such as murmurs or extra heart sounds.

Nurselytic

NCLEX-RN

NCLEX-RN