NCLEX-RN
NCLEX RN Exam Preview Answers Questions
Question 1 of 5
The instructor is teaching a class on basic assessment skills. Which of the following statements is true regarding the stethoscope and its use?
Correct Answer: B
Rationale: The stethoscope does not magnify sound but effectively blocks out extraneous room noises. The correct orientation of the earpieces is with the slope pointing forward toward the examiner's nose, not posteriorly. The tubing length of a stethoscope should ideally be between 14 to 18 inches (36 to 46 cm) to avoid sound distortion. Using tubing longer than this range can distort sound. Both the fit and quality of the stethoscope are crucial for accurate auscultation and assessment, highlighting their significance in clinical practice.
Therefore, the correct answer is that the stethoscope blocks out extraneous room noise but does not magnify sound.
Question 2 of 5
The nurse is reviewing percussion techniques with a new graduate nurse. Which action performed by the graduate nurse while percussing requires the nurse to intervene?
Correct Answer: A
Rationale: The correct answer is to percuss twice over each area, not once. This technique helps ensure a more accurate assessment. Striking with the fingertip instead of the finger pad is correct because the tip of the finger produces clearer sounds. Using the wrist to make the strikes instead of the arm is appropriate as it allows for more controlled and precise percussion. Quickly lifting the striking finger after each stroke is also correct to prevent damping off vibrations.
Therefore, percussing once over each area (
Choice
A) is incorrect as it does not follow the standard percussion technique.
Question 3 of 5
During an assessment, the nurse notices that a patient is handling a small charm that is tied to a leather strip around their neck. Which action by the nurse is appropriate?
Correct Answer: A
Rationale: The small charm tied to a leather strip is likely an amulet, which many cultures consider an important means of protection from 'evil spirits.' When a patient appears to have a health practice the nurse is unfamiliar with, the nurse should ask for clarification in a non-judgmental way that communicates acceptance of their beliefs and allows for open communication. Thus, the nurse in this situation should inquire about the amulet's meaning to the patient. Asking the patient to lock the item with other valuables in the hospital's safe, telling the patient that a family member should take valuables home, or doing nothing does not address the importance or meaning of a cultural health practice to the patient and does not allow the nurse to gain an understanding of the patient's cultural health practices.
Question 4 of 5
When providing culturally competent care, nurses must incorporate cultural assessments into their health assessments. Which statement is most appropriate to use when initiating an assessment of cultural beliefs with an older American Indian patient?
Correct Answer: D
Rationale: The nurse needs to assess the cultural beliefs and practices of the patient and should ask questions in a way that communicates acceptance of their beliefs and allows for open communication.
Therefore, the most appropriate question to initiate an assessment of cultural beliefs with an older American Indian patient is "What cultural or spiritual beliefs are important to you?"? This question shows respect for the patient's beliefs and encourages them to share relevant information. Asking if they are of the Christian faith does not promote open communication and may not reflect the patient's actual beliefs. While some American Indians may seek assistance from a medicine man or shaman, it is not appropriate to make assumptions without direct input from the patient. Asking how often they seek help from medical providers is not directly related to understanding their cultural beliefs and may not provide relevant insights for culturally competent care.
Question 5 of 5
The nurse receives change-of-shift report on the following four patients. Which patient should the nurse assess first?
Correct Answer: B
Rationale: The correct answer is the 46-year-old patient on bed rest who is complaining of sudden onset of shortness of breath. Patients on bed rest who are immobile are at high risk for deep vein thrombosis (DVT). Sudden onset of shortness of breath in a patient with a DVT suggests a pulmonary embolism, which requires immediate assessment and action such as oxygen administration to maintain adequate oxygenation. The other patients should also be assessed as soon as possible, but they do not present with an immediate life-threatening condition that requires urgent intervention like the patient experiencing sudden shortness of breath.