NCLEX-RN
NCLEX RN Exam Preview Answers Questions
Extract:
Question 1 of 5
Which action is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)?
Correct Answer: B
Rationale: Labeling specimens obtained during a percutaneous lung biopsy is a task that can be appropriately delegated to unlicensed assistive personnel (UAP) as it does not require nursing judgment. UAP can perform this task safely under the supervision of a nurse. Listening to a patient's lung sounds for wheezes or rhonchi, instructing a patient about how to use home spirometry testing, and measuring induration at the site of a patient's intradermal skin test all require nursing judgment and interpretation of findings. These tasks should be performed by licensed nursing personnel to ensure accurate assessment and appropriate intervention.
Question 2 of 5
When is the best time for the nurse to attempt to elicit the Moro reflex during an infant examination?
Correct Answer: B
Rationale: The Moro reflex, also known as the startle reflex, is best elicited at the end of the examination because it can cause the infant to cry. This reflex is triggered by a sudden change in position or loud noise, and it involves the infant's arms extending and then coming back together as if embracing. By eliciting this reflex at the end of the examination, the nurse can observe the infant's response and ensure that the examination is completed without unnecessary distress.
Choices A, C, and D are incorrect because the Moro reflex is typically elicited at the end of the examination to avoid disrupting the assessment process and causing unnecessary discomfort to the infant.
Question 3 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 4 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 5 of 5
A 2-year-old child has been brought to the clinic for a well-child checkup. What is the best way for the nurse to begin the assessment?
Correct Answer: C
Rationale: The best place to examine the toddler is on the parent's lap.
Toddlers understand symbols; therefore, a security object is helpful. Initially, the focus is more on the parent, which allows the child to adjust gradually and to become familiar with you. A 2-year-old child does not like to take off his or her clothes.
Therefore, ask the parent to undress one body part at a time.