NCLEX-RN
NCLEX RN Exam Preview Answers Questions
Extract:
Question 1 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 2 of 5
The healthcare provider is preparing to use an otoscope for an examination. Which statement is true regarding the otoscope?
Correct Answer: D
Rationale: The otoscope is a tool used to examine the ear canal and tympanic membrane, which separates the external and middle ear. It is not intended to direct light into the sinuses or examine the internal structures of the ear. The otoscope typically uses a short, narrow speculum to aid in visualizing the ear canal and tympanic membrane, not a short, broad speculum as mentioned in choice C.
Question 3 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 4 of 5
In which situation would the nurse use bimanual palpation technique?
Correct Answer: B
Rationale: Bimanual palpation involves using both hands to envelop or capture specific body parts or organs like the kidneys, uterus, or adnexa. This technique is particularly useful for assessing the size, shape, consistency, and mobility of deep organs like the kidneys and uterus. Palpating the thorax of an infant (
Choice
A) is usually done with a different technique like gentle, single-handed palpation. Assessing pulsations and vibrations (
Choice
C) and assessing tenderness and pain (
Choice
D) typically do not require the use of bimanual palpation, making
Choices A, C, and D incorrect.
Question 5 of 5
Mrs. D is a pregnant client who is 33 weeks' gestation and is admitted for bright red vaginal bleeding. Her physician suspects placenta previa. All of the following nursing interventions are appropriate for this client except:
Correct Answer: C
Rationale: A client with placenta previa has part of the placenta covering some or all of the cervical opening. Performing a vaginal exam for placenta previa may cause significant bleeding and should be avoided unless directed by a physician, and preparations are made for emergency delivery. **
Choice A** is correct as complete bed rest is essential to decrease the risk of further bleeding. **
Choice B** is appropriate as assessing uterine tone helps in determining the condition of the uterus and can provide important information for the healthcare team. **
Choice D** is also a necessary intervention as monitoring and recording blood loss is crucial in assessing the client's condition and response to treatment.