NCLEX-RN
NCLEX RN Exam Preview Answers Questions
Extract:
Question 1 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 2 of 5
A patient has suddenly developed shortness of breath and appears to be in significant respiratory distress. After calling the physician and placing the patient on oxygen, which of these actions is the best for the nurse to take when further assessing the patient?
Correct Answer: B
Rationale: In a situation where a patient is in significant respiratory distress, bilaterally percussing the thorax to note any differences in percussion tones is a crucial nursing intervention. Percussion provides instant feedback regarding changes in underlying tissue density, which can give important clues about the patient's physical status. This hands-on assessment technique is readily available and can be performed promptly. Counting the patient's respirations, while important, may not provide as much detailed information as percussion. Ordering a chest x-ray and waiting for the results can cause a delay in assessing and addressing the patient's immediate needs. Inspecting the thorax for new masses and bleeding, although relevant, may not offer as much real-time information about the patient's condition compared to percussion.
Question 3 of 5
The nurse is preparing to perform a physical assessment. The correct action by the nurse is reflected by which statement?
Correct Answer: D
Rationale: The nurse should organize the assessment to minimize the patient's need to change positions frequently, ensuring efficiency and comfort. It is essential to perform the examination from both sides of the bed to facilitate a comprehensive assessment. Examining tender or painful areas last can help reduce patient discomfort and anxiety. The examination sequence should be flexible, taking into account the patient's age, condition, and specific needs. This approach allows for a tailored and patient-centered assessment, optimizing the quality of care provided.
Question 4 of 5
The healthcare provider is preparing to perform a physical assessment. Which statement is true about the inspection phase of the physical assessment?
Correct Answer: B
Rationale: During the inspection phase of a physical assessment, it is essential to take time as it can reveal a significant amount of information. Initially, it may feel uncomfortable for the examiner to focus solely on observing the patient without immediate action. Rushing through inspection is not recommended as it can lead to missing important cues. Train yourself to be thorough during inspection by observing carefully and taking the time needed to gather essential data.
Choices A, C, and D are incorrect because inspection typically provides valuable information, may feel uncomfortable at first but is necessary for a comprehensive assessment, and does not involve a quick glance but requires a focused and detailed observation.
Question 5 of 5
Many Asians believe in the yin/yang theory, which is rooted in the ancient Chinese philosophy of Tao. Which statement most accurately reflects this philosophy's view of "health"??
Correct Answer: C
Rationale: In the yin/yang theory rooted in ancient Chinese philosophy, health is believed to exist when all aspects of a person are in perfect balance. This includes physical, mental, emotional, and spiritual well-being.
Choice C accurately reflects this philosophy's view of health.
Choices A, B, and D do not capture the essence of the yin/yang theory. Being able to work and produce, being happy and stable, or caring for others and functioning socially, while important, do not encompass the holistic balance emphasized in the yin/yang theory.