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NCLEX STYLE EXAM LATEST 2025 EXAM QUESTIONS AND
CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED
ANSWERS) ALREADY GRADED A+
Over which abdominal quadrant are bowel sounds most active and therefore
easiest to auscultate? - CORRECT ANSWER -Right lower quadrant
Over which abdominal quadrant are bowel sounds most active and therefore
easiest to auscultate?
As part of your general patient survey, you find that your patient has a body
mass index (BMI) of 23. From this finding, you can conclude that your patient -
CORRECT ANSWER -Has body mass index within normal limits
BMI is a measurement of an adult's body fat based on height and weight.
Generally, a BMI between 18.5 and 24.9 reflects a normal weight with a
normal amount of body fat. A patient with a BMI below 18.5 is considered
underweight; a patient with a BMI of 25 or above is considered overweight;
and one with a BMI of 30 or above is considered obese.
While performing a head-to-toe assessment, you perform the Romberg test.
You do this to test the patient's - CORRECT ANSWER -Balance
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The most common test of balance is the Romberg test. Ask the patient to stand
about 2 feet in front of you, with her feet together, toes pointed forward, and
her hands at her sides. While you extend your hands so that one is on either
side of the patient, ask her to close her eyes. Watch to see how well she can
maintain balance in that position. A minimum of swaying is normal, but if the
patient sways more than a couple of inches, stop the test and document that
the patient demonstrated difficulty maintaining balance on Romberg testing.
When using and maintaining your stethoscope, it is important to -
CORRECT ANSWER -Insert the earpieces at an angle toward your nose
Angling the earpieces toward your nose helps ensure that sounds are
effectively transmitted to your eardrums.
You are performing a physical examination of the spine for an older adult.
Which of the following findings is common with aging? - CORRECT
ANSWER -Kyphosis
Kyphosis, a pronounced "hunchback" curvature of the spine, is an abnormal
angulation of the posterior curve of the thoracic spine, usually a result of
osteoporosis. It is most common in older adults and tends to increase with
aging. This pronounced convexity of the thoracic spine is also common in
older patients who have had vertebral fractures.
When performing a respiratory assessment, you auscultate wet, popping
sounds at the inspiratory phase of each respiratory cycle. These sounds are
best identified as - CORRECT ANSWER -crackles
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Crackles, which are sometimes called rales, are wet, popping sounds created
by air moving through liquid or by collapsed alveoli snapping open on
inspiration. They are most common at the end of inspiration.
When performing a complete, head-to-toe physical examination, which
physical-assessment technique should you perform first? - CORRECT
ANSWER -Inspection
Inspection is the process of observation. You will first inspect the body
systematically, observing for normal as well as abnormal physical signs. When
assessing most body systems, the recommended order is inspection,
palpation, percussion, and auscultation. Abdominal assessment is an
exception, since any manipulation of or pressure on the abdomen may
stimulate peristalsis, the waves of contraction that propel contents through
the gastrointestinal tract, and thus alter the patient's bowel sounds. So, when
assessing the abdomen, inspection is still first, but auscultation comes before
percussion and palpation.
What is your primary goal in performing a comprehensive physical
assessment? - CORRECT ANSWER -To develop a plan of care
Remember the nursing process: assessment, diagnosis, planning,
implementation, evaluation. Assessment is the first part of the process. It
generates the database from which you will make nursing decisions. Your
objective in interacting with patients is to identify their needs and concerns
and help find solutions. That is the nursing process in action - and your map is
the nursing care plan you establish for each patient. Analyzing and
synthesizing data will provide the basis for each nursing diagnosis and for the
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selection of nursing interventions to manage actual or potential health
problems.
While performing a cardiovascular assessment, you might encounter a variety
of pulsations and sounds. Which of the following findings is considered
normal? - CORRECT ANSWER -A brief thump felt near the fourth or
fifth intercostal space near the left midclavicular line
This is where you would inspect and palpate for the point of maximal impulse.
Also called an apical pulsation, it occurs as the apex of the heart bumps
against the chest wall with each heartbeat. The apical impulse is not always
visible but can be felt as a brief thump. This is a normal and expected finding
when you are preparing to auscultate an apical pulse.
A nurse is caring for a group of clients. Which of the following actions by the
nurse demonstrates the use of critical thinking skills? - CORRECT
ANSWER -Intervene after reviewing arterial blood gas results for a client
who is on mechanical ventilation.
The nurse is using critical thinking when analyzing a client's critical issues and
then planning to intervene with an appropriate action.
A nurse is following the steps of the nursing process when caring for a group
of clients. Which of the following actions by the nurse demonstrates the
evaluation step of the nursing process? - CORRECT ANSWER -Check
and document a client's pain level 30 min after administering pain medication.
NCLEX STYLE EXAM LATEST 2025 EXAM QUESTIONS AND
CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED
ANSWERS) ALREADY GRADED A+
Over which abdominal quadrant are bowel sounds most active and therefore
easiest to auscultate? - CORRECT ANSWER -Right lower quadrant
Over which abdominal quadrant are bowel sounds most active and therefore
easiest to auscultate?
As part of your general patient survey, you find that your patient has a body
mass index (BMI) of 23. From this finding, you can conclude that your patient -
CORRECT ANSWER -Has body mass index within normal limits
BMI is a measurement of an adult's body fat based on height and weight.
Generally, a BMI between 18.5 and 24.9 reflects a normal weight with a
normal amount of body fat. A patient with a BMI below 18.5 is considered
underweight; a patient with a BMI of 25 or above is considered overweight;
and one with a BMI of 30 or above is considered obese.
While performing a head-to-toe assessment, you perform the Romberg test.
You do this to test the patient's - CORRECT ANSWER -Balance
, Page 2 of 50
The most common test of balance is the Romberg test. Ask the patient to stand
about 2 feet in front of you, with her feet together, toes pointed forward, and
her hands at her sides. While you extend your hands so that one is on either
side of the patient, ask her to close her eyes. Watch to see how well she can
maintain balance in that position. A minimum of swaying is normal, but if the
patient sways more than a couple of inches, stop the test and document that
the patient demonstrated difficulty maintaining balance on Romberg testing.
When using and maintaining your stethoscope, it is important to -
CORRECT ANSWER -Insert the earpieces at an angle toward your nose
Angling the earpieces toward your nose helps ensure that sounds are
effectively transmitted to your eardrums.
You are performing a physical examination of the spine for an older adult.
Which of the following findings is common with aging? - CORRECT
ANSWER -Kyphosis
Kyphosis, a pronounced "hunchback" curvature of the spine, is an abnormal
angulation of the posterior curve of the thoracic spine, usually a result of
osteoporosis. It is most common in older adults and tends to increase with
aging. This pronounced convexity of the thoracic spine is also common in
older patients who have had vertebral fractures.
When performing a respiratory assessment, you auscultate wet, popping
sounds at the inspiratory phase of each respiratory cycle. These sounds are
best identified as - CORRECT ANSWER -crackles
, Page 3 of 50
Crackles, which are sometimes called rales, are wet, popping sounds created
by air moving through liquid or by collapsed alveoli snapping open on
inspiration. They are most common at the end of inspiration.
When performing a complete, head-to-toe physical examination, which
physical-assessment technique should you perform first? - CORRECT
ANSWER -Inspection
Inspection is the process of observation. You will first inspect the body
systematically, observing for normal as well as abnormal physical signs. When
assessing most body systems, the recommended order is inspection,
palpation, percussion, and auscultation. Abdominal assessment is an
exception, since any manipulation of or pressure on the abdomen may
stimulate peristalsis, the waves of contraction that propel contents through
the gastrointestinal tract, and thus alter the patient's bowel sounds. So, when
assessing the abdomen, inspection is still first, but auscultation comes before
percussion and palpation.
What is your primary goal in performing a comprehensive physical
assessment? - CORRECT ANSWER -To develop a plan of care
Remember the nursing process: assessment, diagnosis, planning,
implementation, evaluation. Assessment is the first part of the process. It
generates the database from which you will make nursing decisions. Your
objective in interacting with patients is to identify their needs and concerns
and help find solutions. That is the nursing process in action - and your map is
the nursing care plan you establish for each patient. Analyzing and
synthesizing data will provide the basis for each nursing diagnosis and for the
, Page 4 of 50
selection of nursing interventions to manage actual or potential health
problems.
While performing a cardiovascular assessment, you might encounter a variety
of pulsations and sounds. Which of the following findings is considered
normal? - CORRECT ANSWER -A brief thump felt near the fourth or
fifth intercostal space near the left midclavicular line
This is where you would inspect and palpate for the point of maximal impulse.
Also called an apical pulsation, it occurs as the apex of the heart bumps
against the chest wall with each heartbeat. The apical impulse is not always
visible but can be felt as a brief thump. This is a normal and expected finding
when you are preparing to auscultate an apical pulse.
A nurse is caring for a group of clients. Which of the following actions by the
nurse demonstrates the use of critical thinking skills? - CORRECT
ANSWER -Intervene after reviewing arterial blood gas results for a client
who is on mechanical ventilation.
The nurse is using critical thinking when analyzing a client's critical issues and
then planning to intervene with an appropriate action.
A nurse is following the steps of the nursing process when caring for a group
of clients. Which of the following actions by the nurse demonstrates the
evaluation step of the nursing process? - CORRECT ANSWER -Check
and document a client's pain level 30 min after administering pain medication.
