NCLEX-RN
NCLEX RN Exam Preview Answers Questions
Extract:
Question 1 of 5
An Asian-American woman is experiencing diarrhea, which is believed to be "cold"? or "yin."? What should the nurse recognize that the woman may likely try to treat it?
Correct Answer: A
Rationale: In this scenario, the Asian-American woman is believed to be experiencing diarrhea due to a "cold"? or "yin"? imbalance. According to the yin/yang theory, yang represents heat and yin represents cold.
Therefore, to balance the cold nature of the diarrhea, the woman may try to treat it by consuming foods that are considered "hot"? or "yang"?. This aligns with the concept that cold foods are eaten with a hot illness, and hot foods are eaten with a cold illness.
Choices B, C, and D do not align with the yin/yang theory and are not relevant to addressing the imbalance associated with the cold nature of the diarrhea.
Question 2 of 5
Mrs. D is a pregnant client who is 33 weeks' gestation and is admitted for bright red vaginal bleeding. Her physician suspects placenta previa. All of the following nursing interventions are appropriate for this client except:
Correct Answer: C
Rationale: A client with placenta previa has part of the placenta covering some or all of the cervical opening. Performing a vaginal exam for placenta previa may cause significant bleeding and should be avoided unless directed by a physician, and preparations are made for emergency delivery. **
Choice A** is correct as complete bed rest is essential to decrease the risk of further bleeding. **
Choice B** is appropriate as assessing uterine tone helps in determining the condition of the uterus and can provide important information for the healthcare team. **
Choice D** is also a necessary intervention as monitoring and recording blood loss is crucial in assessing the client's condition and response to treatment.
Question 3 of 5
While auscultating heart sounds, the nurse hears a murmur. Which of these instruments would be used to assess this murmur?
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.
Question 4 of 5
Which theory reflects the view that illness is caused by an imbalance or disharmony in the forces of nature?
Correct Answer: B
Rationale: The naturalistic theory posits that illness results from an imbalance or disharmony in the forces of nature. According to this theory, maintaining a natural balance or harmony is essential to prevent illness. Conversely, germ theory and biomedical or scientific theory attribute illness to microorganisms, while magicoreligious theory attributes illness to supernatural forces such as deities or spirits.
Therefore, the most appropriate theory reflecting the belief that illness arises from a disruption in natural forces is the naturalistic theory.
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.