Crush the NCLEX-PN 2025/2026 – 260 Real Exam
Questions With A+ Verified Answers & Expert
Rationales
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
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
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 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.
The nurse is evaluating, which is the final step of the nursing process, to determine if the
pain medication administered to the client is effective. Evaluation is the same as assessment;
however, to determine the client's status and progress, evaluation is performed.
, A nurse is implementing priority-based interventions for a group of clients. Which of the
following clients should the nurse see first? - Correct Answer-A client who has a cast on a
compound fracture and has SaO2 of 88%
When using the airway, breathing, circulation approach to client care, the nurse should
determine that the finding of SaO2 of 88% indicates hypoxia and requires priority-based
interventions.
A nurse is admitting a client who reports increased thirst and fatigue. Which of the following
actions should the nurse include in the assessment step of the nursing process? - Correct
Answer-Ask the client when the condition started.
Assessment is the first step of the nursing process, where the nurse gathers subjective and
objective information about the client's condition.
A nurse is preparing a plan of care for a client who is experiencing pain after surgery. Which
of the following components should the nurse identify as part of the planning step of the
nursing process? - Correct Answer-Formulate client goals for prioritized problem.
Formulating client goals for prioritized problems is a component of planning, which is the
third step in the nursing process.
The nurse has completed client teaching regarding medication administration. Which client
statement best illustrates compliance?
1. Im glad to know about my medications. It makes taking them a lot easier.
2. I already knew most of what you told me.
3. I think you should have waited until I was ready to go home. Maybe Id remember better.
Questions With A+ Verified Answers & Expert
Rationales
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
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
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 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.
The nurse is evaluating, which is the final step of the nursing process, to determine if the
pain medication administered to the client is effective. Evaluation is the same as assessment;
however, to determine the client's status and progress, evaluation is performed.
, A nurse is implementing priority-based interventions for a group of clients. Which of the
following clients should the nurse see first? - Correct Answer-A client who has a cast on a
compound fracture and has SaO2 of 88%
When using the airway, breathing, circulation approach to client care, the nurse should
determine that the finding of SaO2 of 88% indicates hypoxia and requires priority-based
interventions.
A nurse is admitting a client who reports increased thirst and fatigue. Which of the following
actions should the nurse include in the assessment step of the nursing process? - Correct
Answer-Ask the client when the condition started.
Assessment is the first step of the nursing process, where the nurse gathers subjective and
objective information about the client's condition.
A nurse is preparing a plan of care for a client who is experiencing pain after surgery. Which
of the following components should the nurse identify as part of the planning step of the
nursing process? - Correct Answer-Formulate client goals for prioritized problem.
Formulating client goals for prioritized problems is a component of planning, which is the
third step in the nursing process.
The nurse has completed client teaching regarding medication administration. Which client
statement best illustrates compliance?
1. Im glad to know about my medications. It makes taking them a lot easier.
2. I already knew most of what you told me.
3. I think you should have waited until I was ready to go home. Maybe Id remember better.
