NCLEX-RN
NCLEX RN Exam Preview Answers Questions
Extract:
Question 1 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 2 of 5
When performing a physical assessment, what technique should the nurse always perform first?
Correct Answer: B
Rationale: During a physical assessment, the nurse should always begin with inspection. The sequence of techniques for physical examination is inspection, palpation, percussion, and auscultation. These skills are performed in a specific order, except for the abdominal assessment where auscultation precedes palpation and percussion. Inspection allows the nurse to observe and gather initial information without direct contact. It is a crucial step that provides valuable insights before proceeding to palpation, percussion, and auscultation.
Therefore, choice B, 'Inspection,' is the correct answer.
Choices A, C, and D are incorrect because they should follow inspection in the sequence of a comprehensive physical assessment.
Question 3 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 4 of 5
The nurse is examining a 2-year-old child and asks, "May I listen to your heart now?"? Which critique of the nurse's technique is most accurate?
Correct Answer: D
Rationale: Children at the age of 2 often like to assert their independence by saying "No."? In situations where there is actually no choice available, offering a false choice can lead to a lack of trust. It is important not to offer a choice when there isn't one, as doing so may undermine trust. While asking for permission can enhance autonomy and trust, offering a limited option like, "Shall I listen to your heart next or your tummy?"? may be a better approach.
Therefore, the correct critique of the nurse's technique in this scenario is that children at this age tend to say "No,"? so the examiner should avoid offering a choice when there isn't a real alternative.
Question 5 of 5
The nurse is preparing to assess a hospitalized patient who is experiencing significant shortness of breath. How should the nurse proceed with the assessment?
Correct Answer: D
Rationale: When assessing a patient experiencing significant shortness of breath, it is crucial to prioritize the evaluation of areas directly related to the problem. Having the patient lie down may exacerbate the breathing difficulty.
Therefore, the nurse should focus on examining the body areas pertinent to the issue, such as the respiratory and cardiac systems. Completing the rest of the assessment can be deferred until after addressing the immediate problem. Obtaining a complete history or involving family members should come after addressing the acute issue to ensure the patient's safety and comfort.