NCLEX Style EXAM LATEST 2025
EXAM QUESTIONS AND CORRECT
DETAILED ANSWERS WITH
RATIONALES(VERIFIED
ANSWERS)|ALREADY GRADED A+
Overwhichabdominalquadrantarebowelsoundsmostactiveandthereforeeasiesttoauscultate?-
Correctanswer~Rightlowerquadrant
Overwhichabdominalquadrantarebowelsoundsmostactiveandthereforeeasiesttoauscultate?
Aspartofyourgeneralpatientsurvey,youfindthatyourpatienthasabodymassindex(BMI)of23.Fro
mthisfinding,youcanconcludethatyourpatient-
Correctanswer~Hasbodymassindexwithinnormallimits
BMIisameasurementofanadult'sbodyfatbasedonheightandweight.Generally,aBMIbetween18
.5and24.9reflectsanormalweightwithanormalamountofbodyfat.ApatientwithaBMIbelow18.5
isconsideredunderweight;apatientwithaBMIof25oraboveisconsideredoverweight;andonewit
haBMIof30oraboveisconsideredobese.
Whileperformingahead-to-
toeassessment,youperformtheRombergtest.Youdothistotestthepatient's-
Correctanswer~Balance
ThemostcommontestofbalanceistheRombergtest.Askthepatienttostandabout2feetinfrontofy
ou,withherfeettogether,toespointedforward,andherhandsathersides.Whileyouextendyourha
ndssothatoneisoneithersideofthepatient,askhertoclosehereyes.Watchtoseehowwellshecanm
,aintainbalanceinthatposition.Aminimumofswayingisnormal,butifthepatientswaysmorethana
coupleofinches,stopthetestanddocumentthatthepatientdemonstrateddifficultymaintainingb
alanceonRombergtesting.
Whenusingandmaintainingyourstethoscope,itisimportantto-
Correctanswer~Inserttheearpiecesatanangletowardyournose
Anglingtheearpiecestowardyournosehelpsensurethatsoundsareeffectivelytransmittedtoyour
eardrums.
Youareperformingaphysicalexaminationofthespineforanolderadult.Whichofthefollowingfindi
ngsiscommonwithaging?-Correctanswer~Kyphosis
Kyphosis,apronounced"hunchback"curvatureofthespine,isanabnormalangulationoftheposter
iorcurveofthethoracicspine,usuallyaresultofosteoporosis.Itismostcommoninolderadultsandte
ndstoincreasewithaging.Thispronouncedconvexityofthethoracicspineisalsocommoninolderpa
tientswhohavehadvertebralfractures.
Whenperformingarespiratoryassessment,youauscultatewet,poppingsoundsattheinspiratoryp
haseofeachrespiratorycycle.Thesesoundsarebestidentifiedas-Correctanswer~crackles
Crackles,whicharesometimescalledrales,arewet,poppingsoundscreatedbyairmovingthroughli
quidorbycollapsedalveolisnappingopenoninspiration.Theyaremostcommonattheendofinspira
tion.
Whenperformingacomplete,head-to-toephysicalexamination,whichphysical-
assessmenttechniqueshouldyouperformfirst?-Correctanswer~Inspection
Inspectionistheprocessofobservation.Youwillfirstinspectthebodysystematically,observingforn
ormalaswellasabnormalphysicalsigns.Whenassessingmostbodysystems,therecommendedord
erisinspection,palpation,percussion,andauscultation.Abdominalassessmentisanexception,sin
ceanymanipulationoforpressureontheabdomenmaystimulateperistalsis,thewavesofcontracti
onthatpropelcontentsthroughthegastrointestinaltract,andthusalterthepatient'sbowelsounds.
,So,whenassessingtheabdomen,inspectionisstillfirst,butauscultationcomesbeforepercussiona
ndpalpation.
Whatisyourprimarygoalinperformingacomprehensivephysicalassessment?-
Correctanswer~Todevelopaplanofcare
Rememberthenursingprocess:assessment,diagnosis,planning,implementation,evaluation.Ass
essmentisthefirstpartoftheprocess.Itgeneratesthedatabasefromwhichyouwillmakenursingde
cisions.Yourobjectiveininteractingwithpatientsistoidentifytheirneedsandconcernsandhelpfind
solutions.Thatisthenursingprocessinaction-
andyourmapisthenursingcareplanyouestablishforeachpatient.Analyzingandsynthesizingdata
willprovidethebasisforeachnursingdiagnosisandfortheselectionofnursinginterventionstoman
ageactualorpotentialhealthproblems.
Whileperformingacardiovascularassessment,youmightencounteravarietyofpulsationsandsou
nds.Whichofthefollowingfindingsisconsiderednormal?-
Correctanswer~Abriefthumpfeltnearthefourthorfifthintercostalspaceneartheleftmidclavicula
rline
Thisiswhereyouwouldinspectandpalpateforthepointofmaximalimpulse.Alsocalledanapicalpul
sation,itoccursastheapexoftheheartbumpsagainstthechestwallwitheachheartbeat.Theapicali
mpulseisnotalwaysvisiblebutcanbefeltasabriefthump.Thisisanormalandexpectedfindingwhen
youarepreparingtoauscultateanapicalpulse.
Anurseiscaringforagroupofclients.Whichofthefollowingactionsbythenursedemonstratestheus
eofcriticalthinkingskills?-
Correctanswer~Interveneafterreviewingarterialbloodgasresultsforaclientwhoisonmechanical
ventilation.
Thenurseisusingcriticalthinkingwhenanalyzingaclient'scriticalissuesandthenplanningtointerve
newithanappropriateaction.
Anurseisfollowingthestepsofthenursingprocesswhencaringforagroupofclients.Whichofthefoll
owingactionsbythenursedemonstratestheevaluationstepofthenursingprocess?-
, Correctanswer~Checkanddocumentaclient'spainlevel30minafteradministeringpainmedicatio
n.
Thenurseisevaluating,whichisthefinalstepofthenursingprocess,todetermineifthepainmedicati
onadministeredtotheclientiseffective.Evaluationisthesameasassessment;however,todetermi
netheclient'sstatusandprogress,evaluationisperformed.
Anurseisimplementingpriority-
basedinterventionsforagroupofclients.Whichofthefollowingclientsshouldthenurseseefirst?-
Correctanswer~AclientwhohasacastonacompoundfractureandhasSaO2of88%
Whenusingtheairway,breathing,circulationapproachtoclientcare,thenurseshoulddetermineth
atthefindingofSaO2of88%indicateshypoxiaandrequirespriority-basedinterventions.
Anurseisadmittingaclientwhoreportsincreasedthirstandfatigue.Whichofthefollowingactionssh
ouldthenurseincludeintheassessmentstepofthenursingprocess?-
Correctanswer~Asktheclientwhentheconditionstarted.
Assessmentisthefirststepofthenursingprocess,wherethenursegatherssubjectiveandobjectivei
nformationabouttheclient'scondition.
Anurseispreparingaplanofcareforaclientwhoisexperiencingpainaftersurgery.Whichofthefollo
wingcomponentsshouldthenurseidentifyaspartoftheplanningstepofthenursingprocess?-
Correctanswer~Formulateclientgoalsforprioritizedproblem.
Formulatingclientgoalsforprioritizedproblemsisacomponentofplanning,whichisthethirdstepin
thenursingprocess.
Thenursehascompletedclientteachingregardingmedicationadministration.Whichclientstatem
entbestillustratescompliance?
1.Imgladtoknowaboutmymedications.Itmakestakingthemaloteasier.
EXAM QUESTIONS AND CORRECT
DETAILED ANSWERS WITH
RATIONALES(VERIFIED
ANSWERS)|ALREADY GRADED A+
Overwhichabdominalquadrantarebowelsoundsmostactiveandthereforeeasiesttoauscultate?-
Correctanswer~Rightlowerquadrant
Overwhichabdominalquadrantarebowelsoundsmostactiveandthereforeeasiesttoauscultate?
Aspartofyourgeneralpatientsurvey,youfindthatyourpatienthasabodymassindex(BMI)of23.Fro
mthisfinding,youcanconcludethatyourpatient-
Correctanswer~Hasbodymassindexwithinnormallimits
BMIisameasurementofanadult'sbodyfatbasedonheightandweight.Generally,aBMIbetween18
.5and24.9reflectsanormalweightwithanormalamountofbodyfat.ApatientwithaBMIbelow18.5
isconsideredunderweight;apatientwithaBMIof25oraboveisconsideredoverweight;andonewit
haBMIof30oraboveisconsideredobese.
Whileperformingahead-to-
toeassessment,youperformtheRombergtest.Youdothistotestthepatient's-
Correctanswer~Balance
ThemostcommontestofbalanceistheRombergtest.Askthepatienttostandabout2feetinfrontofy
ou,withherfeettogether,toespointedforward,andherhandsathersides.Whileyouextendyourha
ndssothatoneisoneithersideofthepatient,askhertoclosehereyes.Watchtoseehowwellshecanm
,aintainbalanceinthatposition.Aminimumofswayingisnormal,butifthepatientswaysmorethana
coupleofinches,stopthetestanddocumentthatthepatientdemonstrateddifficultymaintainingb
alanceonRombergtesting.
Whenusingandmaintainingyourstethoscope,itisimportantto-
Correctanswer~Inserttheearpiecesatanangletowardyournose
Anglingtheearpiecestowardyournosehelpsensurethatsoundsareeffectivelytransmittedtoyour
eardrums.
Youareperformingaphysicalexaminationofthespineforanolderadult.Whichofthefollowingfindi
ngsiscommonwithaging?-Correctanswer~Kyphosis
Kyphosis,apronounced"hunchback"curvatureofthespine,isanabnormalangulationoftheposter
iorcurveofthethoracicspine,usuallyaresultofosteoporosis.Itismostcommoninolderadultsandte
ndstoincreasewithaging.Thispronouncedconvexityofthethoracicspineisalsocommoninolderpa
tientswhohavehadvertebralfractures.
Whenperformingarespiratoryassessment,youauscultatewet,poppingsoundsattheinspiratoryp
haseofeachrespiratorycycle.Thesesoundsarebestidentifiedas-Correctanswer~crackles
Crackles,whicharesometimescalledrales,arewet,poppingsoundscreatedbyairmovingthroughli
quidorbycollapsedalveolisnappingopenoninspiration.Theyaremostcommonattheendofinspira
tion.
Whenperformingacomplete,head-to-toephysicalexamination,whichphysical-
assessmenttechniqueshouldyouperformfirst?-Correctanswer~Inspection
Inspectionistheprocessofobservation.Youwillfirstinspectthebodysystematically,observingforn
ormalaswellasabnormalphysicalsigns.Whenassessingmostbodysystems,therecommendedord
erisinspection,palpation,percussion,andauscultation.Abdominalassessmentisanexception,sin
ceanymanipulationoforpressureontheabdomenmaystimulateperistalsis,thewavesofcontracti
onthatpropelcontentsthroughthegastrointestinaltract,andthusalterthepatient'sbowelsounds.
,So,whenassessingtheabdomen,inspectionisstillfirst,butauscultationcomesbeforepercussiona
ndpalpation.
Whatisyourprimarygoalinperformingacomprehensivephysicalassessment?-
Correctanswer~Todevelopaplanofcare
Rememberthenursingprocess:assessment,diagnosis,planning,implementation,evaluation.Ass
essmentisthefirstpartoftheprocess.Itgeneratesthedatabasefromwhichyouwillmakenursingde
cisions.Yourobjectiveininteractingwithpatientsistoidentifytheirneedsandconcernsandhelpfind
solutions.Thatisthenursingprocessinaction-
andyourmapisthenursingcareplanyouestablishforeachpatient.Analyzingandsynthesizingdata
willprovidethebasisforeachnursingdiagnosisandfortheselectionofnursinginterventionstoman
ageactualorpotentialhealthproblems.
Whileperformingacardiovascularassessment,youmightencounteravarietyofpulsationsandsou
nds.Whichofthefollowingfindingsisconsiderednormal?-
Correctanswer~Abriefthumpfeltnearthefourthorfifthintercostalspaceneartheleftmidclavicula
rline
Thisiswhereyouwouldinspectandpalpateforthepointofmaximalimpulse.Alsocalledanapicalpul
sation,itoccursastheapexoftheheartbumpsagainstthechestwallwitheachheartbeat.Theapicali
mpulseisnotalwaysvisiblebutcanbefeltasabriefthump.Thisisanormalandexpectedfindingwhen
youarepreparingtoauscultateanapicalpulse.
Anurseiscaringforagroupofclients.Whichofthefollowingactionsbythenursedemonstratestheus
eofcriticalthinkingskills?-
Correctanswer~Interveneafterreviewingarterialbloodgasresultsforaclientwhoisonmechanical
ventilation.
Thenurseisusingcriticalthinkingwhenanalyzingaclient'scriticalissuesandthenplanningtointerve
newithanappropriateaction.
Anurseisfollowingthestepsofthenursingprocesswhencaringforagroupofclients.Whichofthefoll
owingactionsbythenursedemonstratestheevaluationstepofthenursingprocess?-
, Correctanswer~Checkanddocumentaclient'spainlevel30minafteradministeringpainmedicatio
n.
Thenurseisevaluating,whichisthefinalstepofthenursingprocess,todetermineifthepainmedicati
onadministeredtotheclientiseffective.Evaluationisthesameasassessment;however,todetermi
netheclient'sstatusandprogress,evaluationisperformed.
Anurseisimplementingpriority-
basedinterventionsforagroupofclients.Whichofthefollowingclientsshouldthenurseseefirst?-
Correctanswer~AclientwhohasacastonacompoundfractureandhasSaO2of88%
Whenusingtheairway,breathing,circulationapproachtoclientcare,thenurseshoulddetermineth
atthefindingofSaO2of88%indicateshypoxiaandrequirespriority-basedinterventions.
Anurseisadmittingaclientwhoreportsincreasedthirstandfatigue.Whichofthefollowingactionssh
ouldthenurseincludeintheassessmentstepofthenursingprocess?-
Correctanswer~Asktheclientwhentheconditionstarted.
Assessmentisthefirststepofthenursingprocess,wherethenursegatherssubjectiveandobjectivei
nformationabouttheclient'scondition.
Anurseispreparingaplanofcareforaclientwhoisexperiencingpainaftersurgery.Whichofthefollo
wingcomponentsshouldthenurseidentifyaspartoftheplanningstepofthenursingprocess?-
Correctanswer~Formulateclientgoalsforprioritizedproblem.
Formulatingclientgoalsforprioritizedproblemsisacomponentofplanning,whichisthethirdstepin
thenursingprocess.
Thenursehascompletedclientteachingregardingmedicationadministration.Whichclientstatem
entbestillustratescompliance?
1.Imgladtoknowaboutmymedications.Itmakestakingthemaloteasier.
