NCLEX-RN
NCLEX RN Exam Preview Answers Questions
Extract:
Question 1 of 5
What should the nurse anticipate or expect of an American Indian woman seeking help to regulate her diabetes?
Correct Answer: C
Rationale: When caring for an American Indian patient seeking help for diabetes, the nurse should anticipate that the patient may also seek the assistance of a shaman or medicine man in addition to biomedical treatment. This cultural practice is common among American Indians who believe in holistic healing involving body, mind, and spirit. It is important for the nurse to acknowledge and respect these cultural beliefs and practices.
Choice A is incorrect because patients from different cultures may not always comply with prescribed treatments due to various factors, including cultural beliefs.
Choice B is incorrect as patients seeking traditional healing methods do not necessarily give up their beliefs in naturalistic causes of disease; instead, they often complement biomedical care.
Choice D is incorrect as assuming the patient is experiencing a crisis of faith is not appropriate; it is more about respecting and understanding the patient's cultural background and beliefs.
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
After receiving change-of-shift report, which patient should the nurse assess first?
Correct Answer: B
Rationale: The correct answer is the patient with possible lung cancer who has just returned after bronchoscopy. After bronchoscopy, the patient may have decreased cough and gag reflexes, necessitating immediate assessment for airway patency to prevent potential complications. The other patients do not exhibit urgent clinical manifestations or have undergone recent procedures that require immediate attention.
Therefore, they can be assessed after ensuring the safety and stability of the patient who has just returned after bronchoscopy.
Question 4 of 5
During the examination, it is often appropriate to offer some brief teaching about the patient's body or the examiner's findings. Which one of these statements by the nurse is most appropriate?
Correct Answer: C
Rationale: During an examination, providing brief educational information to the patient can enhance rapport, as long as the patient can comprehend the terminology. The most appropriate statement from the nurse is "Your pulse is 80 beats per minute, which is within the normal range." This statement conveys a vital sign in a way that is likely understandable to the patient.
Choices A, B, and D use terminology that may be unfamiliar or confusing to the patient. Option A mentions 'atrial dysrhythmias,' which might not be clear to the patient. Option B involves terms like 'pitting edema' and 'varicosities,' which could be unfamiliar to the patient. Option D references 'crackles,' 'wheezes,' and 'rubs,' which might not be easily understood by the patient.
Question 5 of 5
The healthcare professional is preparing to auscultate the abdomen. How should they proceed?
Correct Answer: D
Rationale: When preparing to auscultate the abdomen, it is important to ensure the patient's comfort. The room should be warm to prevent shivering, which can interfere with sound clarity. Offering blankets to the patient if they feel cold helps maintain their comfort during the examination. The endpiece of the stethoscope should be warmed by rubbing it between the examiner's hands, not by placing it in warm water. It is important to use the diaphragm, not the bell, of the stethoscope to auscultate for bowel sounds.
Therefore, choice D is the correct answer, as it addresses the patient's comfort and the room temperature, which are essential for a successful abdominal auscultation.