NCLEX Style EXAM LATEST 2025
EXAM QUESTIONS AND CORRECT
DETAILED ANSWERS WITH
RATIONALES(VERIFIED
ANSWERS)|ALREADY 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.
When performing a respiratory assessment, you auscultate wet, popping sounds at the inspiratory
phase of each respiratory cycle. These sounds are best identified as - 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? - 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? - 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 nursing process? -
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? - 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? - 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? -
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.
4. If I take my medications as prescribed, Ill feel better. - answer✔✔✨-1. Im glad to know about my
medications. It makes taking them a lot easier.
A nurse is planning a community health education project that deals with organ donation, and the target
audience is a group of adults. When following andragogy concepts, the nurse should make sure that the
teaching includes which information?
EXAM QUESTIONS AND CORRECT
DETAILED ANSWERS WITH
RATIONALES(VERIFIED
ANSWERS)|ALREADY 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.
When performing a respiratory assessment, you auscultate wet, popping sounds at the inspiratory
phase of each respiratory cycle. These sounds are best identified as - 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? - 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? - 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 nursing process? -
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? - 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? - 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? -
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.
4. If I take my medications as prescribed, Ill feel better. - answer✔✔✨-1. Im glad to know about my
medications. It makes taking them a lot easier.
A nurse is planning a community health education project that deals with organ donation, and the target
audience is a group of adults. When following andragogy concepts, the nurse should make sure that the
teaching includes which information?
