NCLEX Style EXAM LATEST 2025 EXAM
QUESTIONS AND ANSWERS
Overvwhichvabdominalvquadrantvarevbowelvsoundsvmostvactivevandvthereforeveasiestvtovauscultate?v-
vAnswerv-vRightvlowervquadrantv
Overvwhichvabdominalvquadrantvarevbowelvsoundsvmostvactivevandvthereforeveasiestvtovauscultate?
Asvpartvofvyourvgeneralvpatientvsurvey,vyouvfindvthatvyourvpatientvhasvavbodyvmassvindexv(BMI)vofv23
.vFromvthisvfinding,vyouvcanvconcludevthatvyourvpatientv-vAnswerv-
vHasvbodyvmassvindexvwithinvnormalvlimitsv
BMIvisvavmeasurementvofvanvadult'svbodyvfatvbasedvonvheightvandvweight.vGenerally,vavBMIvbetweenv
18.5vandv24.9vreflectsvavnormalvweightvwithvavnormalvamountvofvbodyvfat.vAvpatientvwithvavBMIvbelo
wv18.5visvconsideredvunderweight;vavpatientvwithvavBMIvofv25vorvabovevisvconsideredvoverweight;van
dvonevwithvavBMIvofv30vorvabovevisvconsideredvobese.
Whilevperformingvavhead-to-
toevassessment,vyouvperformvthevRombergvtest.vYouvdovthisvtovtestvthevpatient'sv-vAnswerv-vBalancev
ThevmostvcommonvtestvofvbalancevisvthevRombergvtest.vAskvthevpatientvtovstandvaboutv2vfeetvinvfron
tvofvyou,vwithvhervfeetvtogether,vtoesvpointedvforward,vandvhervhandsvatvhervsides.vWhilevyouvextend
vyourvhandsvsovthatvonevisvonveithervsidevofvthevpatient,vaskvhervtovclosevherveyes.vWatchvtovseevhow
vwellvshevcanvmaintainvbalancevinvthatvposition.vAvminimumvofvswayingvisvnormal,vbutvifvthevpatientvs
waysvmorevthanvavcouplevofvinches,vstopvthevtestvandvdocumentvthatvthevpatientvdemonstratedvdiffic
ultyvmaintainingvbalancevonvRombergvtesting.
Whenvusingvandvmaintainingvyourvstethoscope,vitvisvimportantvtov-vAnswerv-
vInsertvthevearpiecesvatvanvanglevtowardvyourvnosev
,Anglingvthevearpiecesvtowardvyourvnosevhelpsvensurevthatvsoundsvareveffectivelyvtransmittedvtovyourv
eardrums.
Youvarevperformingvavphysicalvexaminationvofvthevspinevforvanvoldervadult.vWhichvofvthevfollowingvfin
dingsvisvcommonvwithvaging?v-vAnswerv-vKyphosisv
Kyphosis,vavpronouncedv"hunchback"vcurvaturevofvthevspine,visvanvabnormalvangulationvofvthevposteri
orvcurvevofvthevthoracicvspine,vusuallyvavresultvofvosteoporosis.vItvisvmostvcommonvinvoldervadultsvan
dvtendsvtovincreasevwithvaging.vThisvpronouncedvconvexityvofvthevthoracicvspinevisvalsovcommonvinvol
dervpatientsvwhovhavevhadvvertebralvfractures.
Whenvperformingvavrespiratoryvassessment,vyouvauscultatevwet,vpoppingvsoundsvatvthevinspiratoryvp
hasevofveachvrespiratoryvcycle.vThesevsoundsvarevbestvidentifiedvasv-vAnswerv-vcracklesv
Crackles,vwhichvarevsometimesvcalledvrales,varevwet,vpoppingvsoundsvcreatedvbyvairvmovingvthroughvli
quidvorvbyvcollapsedvalveolivsnappingvopenvonvinspiration.vTheyvarevmostvcommonvatvthevendvofvinspi
ration.
Whenvperformingvavcomplete,vhead-to-toevphysicalvexamination,vwhichvphysical-
assessmentvtechniquevshouldvyouvperformvfirst?v-vAnswerv-vInspectionv
Inspectionvisvthevprocessvofvobservation.vYouvwillvfirstvinspectvthevbodyvsystematically,vobservingvforv
normalvasvwellvasvabnormalvphysicalvsigns.vWhenvassessingvmostvbodyvsystems,vthevrecommendedvor
dervisvinspection,vpalpation,vpercussion,vandvauscultation.vAbdominalvassessmentvisvanvexception,vsinc
evanyvmanipulationvofvorvpressurevonvthevabdomenvmayvstimulatevperistalsis,vthevwavesvofvcontractio
nvthatvpropelvcontentsvthroughvthevgastrointestinalvtract,vandvthusvaltervthevpatient'svbowelvsounds.v
So,vwhenvassessingvthevabdomen,vinspectionvisvstillvfirst,vbutvauscultationvcomesvbeforevpercussionva
ndvpalpation.
Whatvisvyourvprimaryvgoalvinvperformingvavcomprehensivevphysicalvassessment?v-vAnswerv-
vTovdevelopvavplanvofvcarev
Remembervthevnursingvprocess:vassessment,vdiagnosis,vplanning,vimplementation,vevaluation.vAssess
mentvisvthevfirstvpartvofvthevprocess.vItvgeneratesvthevdatabasevfromvwhichvyouvwillvmakevnursingvde
cisions.vYourvobjectivevinvinteractingvwithvpatientsvisvtovidentifyvtheirvneedsvandvconcernsvandvhelpvfi
,ndvsolutions.vThatvisvthevnursingvprocessvinvactionv-
vandvyourvmapvisvthevnursingvcarevplanvyouvestablishvforveachvpatient.vAnalyzingvandvsynthesizingvdat
avwillvprovidevthevbasisvforveachvnursingvdiagnosisvandvforvthevselectionvofvnursingvinterventionsvtovm
anagevactualvorvpotentialvhealthvproblems.
Whilevperformingvavcardiovascularvassessment,vyouvmightvencountervavvarietyvofvpulsationsvandvsoun
ds.vWhichvofvthevfollowingvfindingsvisvconsideredvnormal?v-vAnswerv-
vAvbriefvthumpvfeltvnearvthevfourthvorvfifthvintercostalvspacevnearvthevleftvmidclavicularvline
Thisvisvwherevyouvwouldvinspectvandvpalpatevforvthevpointvofvmaximalvimpulse.vAlsovcalledvanvapicalv
pulsation,vitvoccursvasvthevapexvofvthevheartvbumpsvagainstvthevchestvwallvwithveachvheartbeat.vTheva
picalvimpulsevisvnotvalwaysvvisiblevbutvcanvbevfeltvasvavbriefvthump.vThisvisvavnormalvandvexpectedvfin
dingvwhenvyouvarevpreparingvtovauscultatevanvapicalvpulse.
Avnursevisvcaringvforvavgroupvofvclients.vWhichvofvthevfollowingvactionsvbyvthevnursevdemonstratesvth
evusevofvcriticalvthinkingvskills?v-vAnswerv-
vIntervenevaftervreviewingvarterialvbloodvgasvresultsvforvavclientvwhovisvonvmechanicalvventilation.
Thevnursevisvusingvcriticalvthinkingvwhenvanalyzingvavclient'svcriticalvissuesvandvthenvplanningvtovinterv
enevwithvanvappropriatevaction.
Avnursevisvfollowingvthevstepsvofvthevnursingvprocessvwhenvcaringvforvavgroupvofvclients.vWhichvofvth
evfollowingvactionsvbyvthevnursevdemonstratesvthevevaluationvstepvofvthevnursingvprocess?v-vAnswerv-
vCheckvandvdocumentvavclient'svpainvlevelv30vminvaftervadministeringvpainvmedication.
Thevnursevisvevaluating,vwhichvisvthevfinalvstepvofvthevnursingvprocess,vtovdeterminevifvthevpainvmedic
ationvadministeredvtovthevclientvisveffective.vEvaluationvisvthevsamevasvassessment;vhowever,vtovdeter
minevthevclient'svstatusvandvprogress,vevaluationvisvperformed.
Avnursevisvimplementingvpriority-
basedvinterventionsvforvavgroupvofvclients.vWhichvofvthevfollowingvclientsvshouldvthevnursevseevfirst?v-
vAnswerv-vAvclientvwhovhasvavcastvonvavcompoundvfracturevandvhasvSaO2v ofv88%
Whenvusingvthevairway,vbreathing,vcirculationvapproachvtovclientvcare,vthevnursevshouldvdeterminevth
atvthevfindingvofvSaO2vofv88%vindicatesvhypoxiavandvrequiresvpriority-basedvinterventions.
, Avnursevisvadmittingvavclientvwhovreportsvincreasedvthirstvandvfatigue.vWhichvofvthevfollowingvactions
vshouldvthevnursevincludevinvthevassessmentvstepvofvthevnursingvprocess?v-vAnswerv-
vAskvthevclientvwhenvthevconditionvstarted.
Assessmentvisvthevfirstvstepvofvthevnursingvprocess,vwherevthevnursevgathersvsubjectivevandvobjective
vinformationvaboutvthevclient'svcondition.
Avnursevisvpreparingvavplanvofvcarevforvavclientvwhovisvexperiencingvpainvaftervsurgery.vWhichvofvthevf
ollowingvcomponentsvshouldvthevnursevidentifyvasvpartvofvthevplanningvstepvofvthevnursingvprocess?v-
vAnswerv-vFormulatevclientvgoalsvforvprioritizedvproblem.
Formulatingvclientvgoalsvforvprioritizedvproblemsvisvavcomponentvofvplanning,vwhichvisvthevthirdvstepvi
nvthevnursingvprocess.
Thevnursevhasvcompletedvclientvteachingvregardingvmedicationvadministration.vWhichvclientvstatemen
tvbestvillustratesvcompliance?
1.vImvgladvtovknowvaboutvmyvmedications.vItvmakesvtakingvthemvavlotveasier.
2.vIvalreadyvknewvmostvofvwhatvyouvtoldvme.
3.vIvthinkvyouvshouldvhavevwaitedvuntilvIvwasvreadyvtovgovhome.vMaybevIdvremembervbetter.
4.vIfvIvtakevmyvmedicationsvasvprescribed,vIllvfeelvbetter.v-vAnswerv-
v1.vImvgladvtovknowvaboutvmyvmedications.vItvmakesvtakingvthemvavlotveasier.
Avnursevisvplanningvavcommunityvhealthveducationvprojectvthatvdealsvwithvorganvdonation,vandvthevta
rgetvaudiencevisvavgroupvofvadults.vWhenvfollowingvandragogyvconcepts,vthevnursevshouldvmakevsurev
thatvthevteachingvincludesvwhichvinformation?
1.vPastvstatisticsvaboutvorganvdonors
QUESTIONS AND ANSWERS
Overvwhichvabdominalvquadrantvarevbowelvsoundsvmostvactivevandvthereforeveasiestvtovauscultate?v-
vAnswerv-vRightvlowervquadrantv
Overvwhichvabdominalvquadrantvarevbowelvsoundsvmostvactivevandvthereforeveasiestvtovauscultate?
Asvpartvofvyourvgeneralvpatientvsurvey,vyouvfindvthatvyourvpatientvhasvavbodyvmassvindexv(BMI)vofv23
.vFromvthisvfinding,vyouvcanvconcludevthatvyourvpatientv-vAnswerv-
vHasvbodyvmassvindexvwithinvnormalvlimitsv
BMIvisvavmeasurementvofvanvadult'svbodyvfatvbasedvonvheightvandvweight.vGenerally,vavBMIvbetweenv
18.5vandv24.9vreflectsvavnormalvweightvwithvavnormalvamountvofvbodyvfat.vAvpatientvwithvavBMIvbelo
wv18.5visvconsideredvunderweight;vavpatientvwithvavBMIvofv25vorvabovevisvconsideredvoverweight;van
dvonevwithvavBMIvofv30vorvabovevisvconsideredvobese.
Whilevperformingvavhead-to-
toevassessment,vyouvperformvthevRombergvtest.vYouvdovthisvtovtestvthevpatient'sv-vAnswerv-vBalancev
ThevmostvcommonvtestvofvbalancevisvthevRombergvtest.vAskvthevpatientvtovstandvaboutv2vfeetvinvfron
tvofvyou,vwithvhervfeetvtogether,vtoesvpointedvforward,vandvhervhandsvatvhervsides.vWhilevyouvextend
vyourvhandsvsovthatvonevisvonveithervsidevofvthevpatient,vaskvhervtovclosevherveyes.vWatchvtovseevhow
vwellvshevcanvmaintainvbalancevinvthatvposition.vAvminimumvofvswayingvisvnormal,vbutvifvthevpatientvs
waysvmorevthanvavcouplevofvinches,vstopvthevtestvandvdocumentvthatvthevpatientvdemonstratedvdiffic
ultyvmaintainingvbalancevonvRombergvtesting.
Whenvusingvandvmaintainingvyourvstethoscope,vitvisvimportantvtov-vAnswerv-
vInsertvthevearpiecesvatvanvanglevtowardvyourvnosev
,Anglingvthevearpiecesvtowardvyourvnosevhelpsvensurevthatvsoundsvareveffectivelyvtransmittedvtovyourv
eardrums.
Youvarevperformingvavphysicalvexaminationvofvthevspinevforvanvoldervadult.vWhichvofvthevfollowingvfin
dingsvisvcommonvwithvaging?v-vAnswerv-vKyphosisv
Kyphosis,vavpronouncedv"hunchback"vcurvaturevofvthevspine,visvanvabnormalvangulationvofvthevposteri
orvcurvevofvthevthoracicvspine,vusuallyvavresultvofvosteoporosis.vItvisvmostvcommonvinvoldervadultsvan
dvtendsvtovincreasevwithvaging.vThisvpronouncedvconvexityvofvthevthoracicvspinevisvalsovcommonvinvol
dervpatientsvwhovhavevhadvvertebralvfractures.
Whenvperformingvavrespiratoryvassessment,vyouvauscultatevwet,vpoppingvsoundsvatvthevinspiratoryvp
hasevofveachvrespiratoryvcycle.vThesevsoundsvarevbestvidentifiedvasv-vAnswerv-vcracklesv
Crackles,vwhichvarevsometimesvcalledvrales,varevwet,vpoppingvsoundsvcreatedvbyvairvmovingvthroughvli
quidvorvbyvcollapsedvalveolivsnappingvopenvonvinspiration.vTheyvarevmostvcommonvatvthevendvofvinspi
ration.
Whenvperformingvavcomplete,vhead-to-toevphysicalvexamination,vwhichvphysical-
assessmentvtechniquevshouldvyouvperformvfirst?v-vAnswerv-vInspectionv
Inspectionvisvthevprocessvofvobservation.vYouvwillvfirstvinspectvthevbodyvsystematically,vobservingvforv
normalvasvwellvasvabnormalvphysicalvsigns.vWhenvassessingvmostvbodyvsystems,vthevrecommendedvor
dervisvinspection,vpalpation,vpercussion,vandvauscultation.vAbdominalvassessmentvisvanvexception,vsinc
evanyvmanipulationvofvorvpressurevonvthevabdomenvmayvstimulatevperistalsis,vthevwavesvofvcontractio
nvthatvpropelvcontentsvthroughvthevgastrointestinalvtract,vandvthusvaltervthevpatient'svbowelvsounds.v
So,vwhenvassessingvthevabdomen,vinspectionvisvstillvfirst,vbutvauscultationvcomesvbeforevpercussionva
ndvpalpation.
Whatvisvyourvprimaryvgoalvinvperformingvavcomprehensivevphysicalvassessment?v-vAnswerv-
vTovdevelopvavplanvofvcarev
Remembervthevnursingvprocess:vassessment,vdiagnosis,vplanning,vimplementation,vevaluation.vAssess
mentvisvthevfirstvpartvofvthevprocess.vItvgeneratesvthevdatabasevfromvwhichvyouvwillvmakevnursingvde
cisions.vYourvobjectivevinvinteractingvwithvpatientsvisvtovidentifyvtheirvneedsvandvconcernsvandvhelpvfi
,ndvsolutions.vThatvisvthevnursingvprocessvinvactionv-
vandvyourvmapvisvthevnursingvcarevplanvyouvestablishvforveachvpatient.vAnalyzingvandvsynthesizingvdat
avwillvprovidevthevbasisvforveachvnursingvdiagnosisvandvforvthevselectionvofvnursingvinterventionsvtovm
anagevactualvorvpotentialvhealthvproblems.
Whilevperformingvavcardiovascularvassessment,vyouvmightvencountervavvarietyvofvpulsationsvandvsoun
ds.vWhichvofvthevfollowingvfindingsvisvconsideredvnormal?v-vAnswerv-
vAvbriefvthumpvfeltvnearvthevfourthvorvfifthvintercostalvspacevnearvthevleftvmidclavicularvline
Thisvisvwherevyouvwouldvinspectvandvpalpatevforvthevpointvofvmaximalvimpulse.vAlsovcalledvanvapicalv
pulsation,vitvoccursvasvthevapexvofvthevheartvbumpsvagainstvthevchestvwallvwithveachvheartbeat.vTheva
picalvimpulsevisvnotvalwaysvvisiblevbutvcanvbevfeltvasvavbriefvthump.vThisvisvavnormalvandvexpectedvfin
dingvwhenvyouvarevpreparingvtovauscultatevanvapicalvpulse.
Avnursevisvcaringvforvavgroupvofvclients.vWhichvofvthevfollowingvactionsvbyvthevnursevdemonstratesvth
evusevofvcriticalvthinkingvskills?v-vAnswerv-
vIntervenevaftervreviewingvarterialvbloodvgasvresultsvforvavclientvwhovisvonvmechanicalvventilation.
Thevnursevisvusingvcriticalvthinkingvwhenvanalyzingvavclient'svcriticalvissuesvandvthenvplanningvtovinterv
enevwithvanvappropriatevaction.
Avnursevisvfollowingvthevstepsvofvthevnursingvprocessvwhenvcaringvforvavgroupvofvclients.vWhichvofvth
evfollowingvactionsvbyvthevnursevdemonstratesvthevevaluationvstepvofvthevnursingvprocess?v-vAnswerv-
vCheckvandvdocumentvavclient'svpainvlevelv30vminvaftervadministeringvpainvmedication.
Thevnursevisvevaluating,vwhichvisvthevfinalvstepvofvthevnursingvprocess,vtovdeterminevifvthevpainvmedic
ationvadministeredvtovthevclientvisveffective.vEvaluationvisvthevsamevasvassessment;vhowever,vtovdeter
minevthevclient'svstatusvandvprogress,vevaluationvisvperformed.
Avnursevisvimplementingvpriority-
basedvinterventionsvforvavgroupvofvclients.vWhichvofvthevfollowingvclientsvshouldvthevnursevseevfirst?v-
vAnswerv-vAvclientvwhovhasvavcastvonvavcompoundvfracturevandvhasvSaO2v ofv88%
Whenvusingvthevairway,vbreathing,vcirculationvapproachvtovclientvcare,vthevnursevshouldvdeterminevth
atvthevfindingvofvSaO2vofv88%vindicatesvhypoxiavandvrequiresvpriority-basedvinterventions.
, Avnursevisvadmittingvavclientvwhovreportsvincreasedvthirstvandvfatigue.vWhichvofvthevfollowingvactions
vshouldvthevnursevincludevinvthevassessmentvstepvofvthevnursingvprocess?v-vAnswerv-
vAskvthevclientvwhenvthevconditionvstarted.
Assessmentvisvthevfirstvstepvofvthevnursingvprocess,vwherevthevnursevgathersvsubjectivevandvobjective
vinformationvaboutvthevclient'svcondition.
Avnursevisvpreparingvavplanvofvcarevforvavclientvwhovisvexperiencingvpainvaftervsurgery.vWhichvofvthevf
ollowingvcomponentsvshouldvthevnursevidentifyvasvpartvofvthevplanningvstepvofvthevnursingvprocess?v-
vAnswerv-vFormulatevclientvgoalsvforvprioritizedvproblem.
Formulatingvclientvgoalsvforvprioritizedvproblemsvisvavcomponentvofvplanning,vwhichvisvthevthirdvstepvi
nvthevnursingvprocess.
Thevnursevhasvcompletedvclientvteachingvregardingvmedicationvadministration.vWhichvclientvstatemen
tvbestvillustratesvcompliance?
1.vImvgladvtovknowvaboutvmyvmedications.vItvmakesvtakingvthemvavlotveasier.
2.vIvalreadyvknewvmostvofvwhatvyouvtoldvme.
3.vIvthinkvyouvshouldvhavevwaitedvuntilvIvwasvreadyvtovgovhome.vMaybevIdvremembervbetter.
4.vIfvIvtakevmyvmedicationsvasvprescribed,vIllvfeelvbetter.v-vAnswerv-
v1.vImvgladvtovknowvaboutvmyvmedications.vItvmakesvtakingvthemvavlotveasier.
Avnursevisvplanningvavcommunityvhealthveducationvprojectvthatvdealsvwithvorganvdonation,vandvthevta
rgetvaudiencevisvavgroupvofvadults.vWhenvfollowingvandragogyvconcepts,vthevnursevshouldvmakevsurev
thatvthevteachingvincludesvwhichvinformation?
1.vPastvstatisticsvaboutvorganvdonors
