NCLEX STYLE EXAM LATEST 2025 EXAM QUESTIONS
AND ANSWERS 100% ACCURATE!!(GRADED A+)
,Over which abdominal quadrant are bowel sounds most active and therefore easiest to
auscultate? - 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 - 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 - 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 - 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? - 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.
, 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? -
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? -
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? - 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
AND ANSWERS 100% ACCURATE!!(GRADED A+)
,Over which abdominal quadrant are bowel sounds most active and therefore easiest to
auscultate? - 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 - 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 - 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 - 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? - 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.
, 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? -
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? -
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? - 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
