NCLEX-RN Ultimate Test Bank 2025–2026 | 300+ Detailed
NCLEX-Style Questions & Rationales | Based on Saunders
10th Edition | Guaranteed Pass | Rated 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
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.
NCLEX-Style Questions & Rationales | Based on Saunders
10th Edition | Guaranteed Pass | Rated 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
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.
