NCLEX-RN
NCLEX RN Exam Preview Answers Questions
Extract:
Question 1 of 5
When examining an older adult, which technique should the nurse use?
Correct Answer: D
Rationale: When examining an older adult, it is crucial to arrange the sequence of the examination to minimize position changes. This helps prevent discomfort and fatigue for the older adult, who may have mobility issues. Option A is incorrect because physical touch is essential when examining older adults, as their other senses may be diminished. Option B is incorrect as it is better to break the examination into multiple visits to ensure thoroughness and comfort. Option C is incorrect because while some older adults may have hearing deficits, it is not appropriate to assume this for all individuals without proper assessment.
Question 2 of 5
An examiner is using an ophthalmoscope to examine a patient's eyes. The patient has astigmatism and is nearsighted. Which of these techniques by the examiner would indicate that the examination is being correctly performed?
Correct Answer: A
Rationale:
To correctly perform an eye examination using an ophthalmoscope on a patient with astigmatism and nearsightedness, the examiner should rotate the lens selector dial to bring the object into focus. This adjustment helps compensate for nearsightedness or farsightedness but does not correct astigmatism. Rotating the lens selector dial to the black numbers is not an appropriate technique for compensating for astigmatism. Using the grid on the lens aperture dial is primarily for visualizing external structures of the eye, not for addressing refractive errors. The large full circle of light is typically used when assessing dilated pupils, not for examining patients with astigmatism and nearsightedness.
Therefore, the correct technique is rotating the lens selector dial to bring the object into focus.
Question 3 of 5
Which of these statements is true regarding the use of Standard Precautions in the healthcare setting?
Correct Answer: C
Rationale: Standard Precautions are designed to reduce the risk for transmission of microorganisms from both recognized and unrecognized sources. They are intended for use with all patients, regardless of their risk or presumed infection status. Standard Precautions apply to all body fluids, secretions, and excretions except sweat - whether or not they contain visible blood, non-intact skin, or mucous membranes. Hands should be washed with soap and water if visibly soiled with blood or body fluids. Alcohol-based hand rubs can be used if hands are not visibly soiled.
Choice A is incorrect because Standard Precautions apply to all body fluids, secretions, and excretions except sweat.
Choice B is incorrect because alcohol-based hand rub should be used when hands are not visibly dirty.
Choice D is incorrect because Standard Precautions are not limited to situations involving non-intact skin, excretions with visible blood, or expected mucous membrane contact.
Question 4 of 5
What action by the nurse is appropriate when examining a 16-year-old male teenager?
Correct Answer: D
Rationale: During the examination of a 16-year-old male teenager, it is essential to provide feedback that his body is developing normally and to discuss the wide variation among teenagers regarding growth and development. This reassures the teenager about his health status and addresses any concerns about physical development. It is important to recognize that adolescents are very conscious of their body image and often compare themselves to their peers, hence the need for such feedback. Asking the parent to step out of the room respects the teenager's privacy and promotes open communication between the nurse and the teenager. Using age-appropriate communication is crucial to ensure that the teenager understands the information provided. Asking the parent to stay in the room may not be ideal as it can inhibit open discussion, and talking to the teenager as if they were a younger child is inappropriate and may undermine their autonomy and understanding.
Question 5 of 5
The nurse is unable to palpate the right radial pulse on a patient. What would the nurse do next?
Correct Answer: C
Rationale: When a nurse is unable to palpate a radial pulse, the next step is to use a Doppler device to check for pulsations over the area. Doppler devices are specifically designed to augment pulse or blood pressure measurements. Auscultating with a fetoscope is used to listen to fetal heart tones and is not relevant in this scenario. Goniometers are used to measure joint range of motion and are not used to assess pulses. Stethoscopes are primarily used to auscultate breath, bowel, and heart sounds, not to check for pulsations in peripheral pulses.
Therefore, the correct course of action when unable to palpate a pulse is to utilize a Doppler device to assess for pulsations in the radial pulse area.