NCLEX Style EXAM LATEST 2025 EXAM QUESTIONS AND CORRECT
DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS)
|ALREADY GRADED A+
Terms in this set (89)
Right lower quadrant
Over which abdominal quadrant
are bowel sounds most active
Over which abdominal quadrant are bowel sounds most active and
and therefore easiest to therefore easiest to auscultate?
auscultate?
Has body mass index within normal limits
As part of your general patient
BMI is a measurement of an adult's body fat based on height and
survey, you find that your
weight. Generally, a BMI between 18.5 and 24.9 reflects a normal
patient has a body mass index
weight with a normal amount of body fat. A patient with a BMI
(BMI) of 23. From this finding,
below 18.5 is considered underweight; a patient with a BMI of
you can conclude that your
25 or above is considered overweight; and one with a BMI of
patient
30 or above is
considered obese.
Balance
The most common test of balance is the Romberg test. Ask the patient to
stand
While performing a head-to-toe
about 2 feet in front of you, with her feet together, toes
assessment, you perform the
pointed forward, and her hands at her sides. While you extend
Romberg test. You do this to
your hands so that one is on either side of the patient, ask her to
test the patient's
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.
, Insert the earpieces at an angle toward your nose
When using and maintaining your
stethoscope, it is important to Angling the earpieces toward your nose helps ensure that
sounds are effectively transmitted to your eardrums.
Kyphosis
You are performing a physical Kyphosis, a pronounced "hunchback" curvature of the spine,
examination of the spine for an is an abnormal angulation of the posterior curve of the
older adult. Which of the thoracic spine, usually a result of
following findings is common osteoporosis. It is most common in older adults and tends to
with aging? increase with aging. This pronounced convexity of the thoracic
spine is also common in older patients who have had
vertebral fractures.
crackles
When performing a respiratory
assessment, you auscultate wet,
Crackles, which are sometimes called rales, are wet, popping
popping sounds at the sounds created by air moving through liquid or by collapsed
inspiratory phase of each alveoli snapping open on inspiration. They are most common at
the end of inspiration.
respiratory cycle. These sounds
are best identified as
Inspection
Inspection is the process of observation. You will first inspect the body
When performing a complete, systematically, observing for normal as well as abnormal
head-to-toe physical physical signs. When assessing most body systems, the
examination, which physical- recommended order is inspection, palpation, percussion, and
assessment technique should auscultation. Abdominal assessment is an exception, since any
you perform first? 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.
, To develop a plan of care
Remember the nursing process: assessment, diagnosis,
planning, implementation, evaluation. Assessment is the first
What is your primary goal in part of the process. It generates the database from which you
performing a comprehensive will make nursing decisions. Your objective in interacting with
physical assessment? 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 selection of nursing interventions
to manage actual or potential health
problems.
A brief thump felt near the fourth or fifth intercostal space near
the left midclavicular line
While performing a cardiovascular
assessment, you might This is where you would inspect and palpate for the point of
encounter a variety of maximal impulse. Also called an apical pulsation, it occurs as the
pulsations and sounds. Which apex of the heart bumps against the chest wall with each
of the heartbeat. The apical impulse is not always visible but can be felt
following findings is considered
normal? as a brief thump. This is a normal and expected finding when
you are preparing to
auscultate an apical pulse.
Intervene after reviewing arterial blood gas results for a client
A nurse is caring for a group of
who is on mechanical ventilation.
clients. Which of the following
actions by the nurse The nurse is using critical thinking when analyzing a client's
demonstrates the use of critical critical issues and then planning to intervene with an
appropriate action.
thinking
skills?
, Check and document a client's pain level 30 min after administering pain
A nurse is following the steps of
medication.
the nursing process when caring
for a group of clients. Which of The nurse is evaluating, which is the final step of the nursing
the following actions by the process, to determine if the pain medication administered to
the client is effective. Evaluation is the same as assessment;
nurse demonstrates the
however, to determine the client's status and progress,
evaluation step of the evaluation is performed.
nursing process?
A client who has a cast on a compound fracture and has SaO2 of 88%
A nurse is implementing priority-
based
interventions for a group of When using the airway, breathing, circulation approach to
clients. Which of the following client care, the nurse should determine that the finding of
clients should the nurse see SaO2 of 88% indicates hypoxia and requires priority-based
first? interventions.
A nurse is admitting a client who Ask the client when the condition started.
reports increased thirst and
fatigue. Which of the Assessment is the first step of the nursing process, where
following actions should the the nurse gathers subjective and objective information
nurse include in the assessment about the client's condition.
step of the nursing
process?
A nurse is preparing a plan of Formulate client goals for prioritized problem.
care for a client who is
experiencing pain after Formulating client goals for prioritized problems is a
surgery. Which of the component of planning, which is the third step in the nursing
following components should process.
the nurse identify as part of
the planning step of the
nursing process?
DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS)
|ALREADY GRADED A+
Terms in this set (89)
Right lower quadrant
Over which abdominal quadrant
are bowel sounds most active
Over which abdominal quadrant are bowel sounds most active and
and therefore easiest to therefore easiest to auscultate?
auscultate?
Has body mass index within normal limits
As part of your general patient
BMI is a measurement of an adult's body fat based on height and
survey, you find that your
weight. Generally, a BMI between 18.5 and 24.9 reflects a normal
patient has a body mass index
weight with a normal amount of body fat. A patient with a BMI
(BMI) of 23. From this finding,
below 18.5 is considered underweight; a patient with a BMI of
you can conclude that your
25 or above is considered overweight; and one with a BMI of
patient
30 or above is
considered obese.
Balance
The most common test of balance is the Romberg test. Ask the patient to
stand
While performing a head-to-toe
about 2 feet in front of you, with her feet together, toes
assessment, you perform the
pointed forward, and her hands at her sides. While you extend
Romberg test. You do this to
your hands so that one is on either side of the patient, ask her to
test the patient's
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.
, Insert the earpieces at an angle toward your nose
When using and maintaining your
stethoscope, it is important to Angling the earpieces toward your nose helps ensure that
sounds are effectively transmitted to your eardrums.
Kyphosis
You are performing a physical Kyphosis, a pronounced "hunchback" curvature of the spine,
examination of the spine for an is an abnormal angulation of the posterior curve of the
older adult. Which of the thoracic spine, usually a result of
following findings is common osteoporosis. It is most common in older adults and tends to
with aging? increase with aging. This pronounced convexity of the thoracic
spine is also common in older patients who have had
vertebral fractures.
crackles
When performing a respiratory
assessment, you auscultate wet,
Crackles, which are sometimes called rales, are wet, popping
popping sounds at the sounds created by air moving through liquid or by collapsed
inspiratory phase of each alveoli snapping open on inspiration. They are most common at
the end of inspiration.
respiratory cycle. These sounds
are best identified as
Inspection
Inspection is the process of observation. You will first inspect the body
When performing a complete, systematically, observing for normal as well as abnormal
head-to-toe physical physical signs. When assessing most body systems, the
examination, which physical- recommended order is inspection, palpation, percussion, and
assessment technique should auscultation. Abdominal assessment is an exception, since any
you perform first? 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.
, To develop a plan of care
Remember the nursing process: assessment, diagnosis,
planning, implementation, evaluation. Assessment is the first
What is your primary goal in part of the process. It generates the database from which you
performing a comprehensive will make nursing decisions. Your objective in interacting with
physical assessment? 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 selection of nursing interventions
to manage actual or potential health
problems.
A brief thump felt near the fourth or fifth intercostal space near
the left midclavicular line
While performing a cardiovascular
assessment, you might This is where you would inspect and palpate for the point of
encounter a variety of maximal impulse. Also called an apical pulsation, it occurs as the
pulsations and sounds. Which apex of the heart bumps against the chest wall with each
of the heartbeat. The apical impulse is not always visible but can be felt
following findings is considered
normal? as a brief thump. This is a normal and expected finding when
you are preparing to
auscultate an apical pulse.
Intervene after reviewing arterial blood gas results for a client
A nurse is caring for a group of
who is on mechanical ventilation.
clients. Which of the following
actions by the nurse The nurse is using critical thinking when analyzing a client's
demonstrates the use of critical critical issues and then planning to intervene with an
appropriate action.
thinking
skills?
, Check and document a client's pain level 30 min after administering pain
A nurse is following the steps of
medication.
the nursing process when caring
for a group of clients. Which of The nurse is evaluating, which is the final step of the nursing
the following actions by the process, to determine if the pain medication administered to
the client is effective. Evaluation is the same as assessment;
nurse demonstrates the
however, to determine the client's status and progress,
evaluation step of the evaluation is performed.
nursing process?
A client who has a cast on a compound fracture and has SaO2 of 88%
A nurse is implementing priority-
based
interventions for a group of When using the airway, breathing, circulation approach to
clients. Which of the following client care, the nurse should determine that the finding of
clients should the nurse see SaO2 of 88% indicates hypoxia and requires priority-based
first? interventions.
A nurse is admitting a client who Ask the client when the condition started.
reports increased thirst and
fatigue. Which of the Assessment is the first step of the nursing process, where
following actions should the the nurse gathers subjective and objective information
nurse include in the assessment about the client's condition.
step of the nursing
process?
A nurse is preparing a plan of Formulate client goals for prioritized problem.
care for a client who is
experiencing pain after Formulating client goals for prioritized problems is a
surgery. Which of the component of planning, which is the third step in the nursing
following components should process.
the nurse identify as part of
the planning step of the
nursing process?
