NCLEX-RN
NCLEX RN Exam Preview Answers Questions
Extract:
Question 1 of 5
While percussing over the liver of a patient, the nurse notices a dull sound. What should the nurse do?
Correct Answer: A
Rationale: When percussing over relatively dense organs, such as the liver or spleen, a dull sound is a normal finding due to the organ's density. This occurs because the sound waves produced by tapping on the organ travel through the dense tissue, resulting in a dull sound.
Therefore, the correct action for the nurse in this scenario is to consider a dull sound over the liver as a normal finding. Palpating for an underlying mass (
Choice
B) is not indicated based on the percussion finding alone. Repositioning the hands and repeating the percussion (
Choice
C) may not change the dull sound over the liver. Referring the patient for additional treatment (
Choice
D) without understanding the normal percussion findings over the liver would be premature. Thus, the most appropriate action is to interpret the dull sound as a normal finding.
Question 2 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.
Question 3 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 4 of 5
During a class on religion and spirituality, the nurse is asked to define spirituality. Which statement by the nurse best describes spirituality?
Correct Answer: D
Rationale: Spirituality is a broad term that focuses on a connection with something greater than oneself and a belief in transcendence. It is a personal journey that arises from unique life experiences and the individual's quest to find purpose and meaning in life. The correct answer emphasizes the essence of spirituality, which involves seeking a connection with a higher power and believing in transcendence.
Choices A, B, and C, on the other hand, define aspects of religion rather than spirituality.
Choice A refers to a personal search for a supreme being, which is more aligned with religious beliefs.
Choice B describes an organized system of beliefs about the universe, typically associated with religion.
Choice C pertains to beliefs about existence after death, such as reincarnation or the afterlife, which are often religious concepts.
Therefore, the best description of spirituality is focusing on a connection with something beyond oneself and a belief in transcendence.
Question 5 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.