NCLEX-RN
NCLEX RN Exam Preview Answers Questions
Extract:
Question 1 of 5
During an examination of a patient's abdomen, the nurse notes that the abdomen is rounded and firm to the touch. During percussion, the nurse notes a drum-like quality of the sounds across the quadrants. How would the nurse interpret this type of sound?
Correct Answer: B
Rationale: A musical or drum-like sound (tympany) is heard when percussion occurs over an air-filled viscus, such as the stomach or intestines. This indicates the presence of air-filled areas. Constipation, choice A, does not produce specific percussion sounds and is related to bowel movements rather than the sound produced during percussion. The presence of a tumor, choice C, would not typically produce a drum-like sound but might result in dullness or decreased resonance. Dense organs, choice D, would produce a dull thud sound rather than a drum-like tympanic sound.
Question 2 of 5
The healthcare professional is preparing to percuss the abdomen of a patient. What characteristic of the underlying tissue does percussion assess?
Correct Answer: C
Rationale: Percussion is a technique used to assess the density of underlying organs by producing sounds that help determine their location and size. Turgor, texture, and consistency are primarily assessed through palpation, not percussion. Turgor refers to skin elasticity, texture pertains to the feel of the tissue surface, and consistency relates to the firmness or resistance of the tissue.
Question 3 of 5
Which of these techniques uses the sense of touch to assess texture, temperature, moisture, and swelling when assessing a patient?
Correct Answer: A
Rationale: The correct answer is Palpation. Palpation involves using the sense of touch to assess texture, temperature, moisture, and swelling in a patient. This technique allows the nurse to feel for abnormalities and changes in the patient's tissues. Inspection primarily relies on visual assessment, while percussion involves tapping on the body to produce sounds and assess underlying structures. Auscultation, on the other hand, involves listening to sounds within the body using a stethoscope.
Therefore, in the context of assessing texture, temperature, moisture, and swelling, palpation is the most appropriate technique.
Question 4 of 5
A 51-year-old woman had an incisional cholecystectomy 6 hours ago. The nurse will place the highest priority on assisting the patient to
Correct Answer: D
Rationale: Postoperative nursing care after a cholecystectomy focuses on preventing respiratory complications due to the surgical incision being high in the abdomen, which impairs coughing and deep breathing. Turning, coughing, and deep breathing every 2 hours help prevent respiratory complications, such as pneumonia. While choices A, B, and C are also important aspects of postoperative care, they are not as high a priority as ensuring proper ventilation and respiratory function in the immediate postoperative period.
Question 5 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.