NCLEX-RN
NCLEX RN Exam Preview Answers Questions
Extract:
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
A 6-month-old infant has been brought to the well-child clinic for a checkup. The infant is currently sleeping. What would the nurse do first when beginning the examination?
Correct Answer: C
Rationale: When the infant is quiet or sleeping, it is an ideal time to assess the cardiac, respiratory, and abdominal systems. It is recommended not to wake the infant unnecessarily. Auscultating the lungs and heart while the infant is still sleeping allows for a comprehensive assessment without disturbing the infant. Examining the infant's hips prematurely may disrupt the infant's sleep. Starting with an assessment of the eye is not appropriate as it is an invasive procedure and should be performed towards the end of the examination after the non-invasive assessments have been completed.
Question 3 of 5
The healthcare provider is reviewing theories of illness. The germ theory, which states that microscopic organisms such as bacteria and viruses are responsible for specific disease conditions, is a basic belief of which theory of illness?
Correct Answer: B
Rationale: The correct answer is B: Biomedical. Among the biomedical explanations for disease is the germ theory, which states that microscopic organisms such as bacteria and viruses are responsible for specific disease conditions. The naturalistic or holistic perspective holds that the forces of nature must be kept in natural balance. The magicoreligious perspective holds that supernatural forces dominate and cause illness or health.
Therefore, options A, C, and D are incorrect as they do not align with the germ theory explanation provided in the question.
Question 4 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.
Question 5 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.