NCLEX STYLE EXAM LATEST 2025
EXAM QUESTIONS AND CORRECT
DETAILED ANSWERS WITH
RATIONALES(VERIFIED ANSWERS)|
ALREADY GRADED A+
Over17which17abdominal17quadrant17are17bowel17sounds17most17active17and17therefor
e17easiest17to17auscultate?17-17ans-Right17lower17quadrant17
Over17which17abdominal17quadrant17are17bowel17sounds17most17active17and17therefor
e17easiest17to17auscultate?
As17part17of17your17general17patient17survey,17you17find17that17your17patient17has17a17
body17mass17index17(BMI)17of1723.17From17this17finding,17you17can17conclude17that17y
our17patient17-17ans-Has17body17mass17index17within17normal17limits17
BMI17is17a17measurement17of17an17adult's17body17fat17based17on17height17and17weigh
t.17Generally,17a17BMI17between1718.517and1724.917reflects17a17normal17weight17with1
7a17normal17amount17of17body17fat.17A17patient17with17a17BMI17below1718.517is17consi
dered17underweight;17a17patient17with17a17BMI17of172517or17above17is17considered17o
verweight;17and17one17with17a17BMI17of173017or17above17is17considered17obese.
While17performing17a17head-to-
toe17assessment,17you17perform17the17Romberg17test.17You17do17this17to17test17the17
patient's17-17ans-Balance17
The17most17common17test17of17balance17is17the17Romberg17test.17Ask17the17patient17t
o17stand17about17217feet17in17front17of17you,17with17her17feet17together,17toes17pointed
17forward,17and17her17hands17at17her17sides.17While17you17extend17your17hands17so17
that17one17is17on17either17side17of17the17patient,17ask17her17to17close17her17eyes.17W
atch17to17see17how17well17she17can17maintain17balance17in17that17position.17A17minim
um17of17swaying17is17normal,17but17if17the17patient17sways17more17than17a17couple17o
f17inches,17stop17the17test17and17document17that17the17patient17demonstrated17difficult
y17maintaining17balance17on17Romberg17testing.
When17using17and17maintaining17your17stethoscope,17it17is17important17to17-17ans-
Insert17the17earpieces17at17an17angle17toward17your17nose17
,Angling17the17earpieces17toward17your17nose17helps17ensure17that17sounds17are17effe
ctively17transmitted17to17your17eardrums.
You17are17performing17a17physical17examination17of17the17spine17for17an17older17adult
.17Which17of17the17following17findings17is17common17with17aging?17-17ans-Kyphosis17
Kyphosis,17a17pronounced17"hunchback"17curvature17of17the17spine,17is17an17abnorma
l17angulation17of17the17posterior17curve17of17the17thoracic17spine,17usually17a17result17
of17osteoporosis.17It17is17most17common17in17older17adults17and17tends17to17increase1
7with17aging.17This17pronounced17convexity17of17the17thoracic17spine17is17also17comm
on17in17older17patients17who17have17had17vertebral17fractures.
When17performing17a17respiratory17assessment,17you17auscultate17wet,17popping17sou
nds17at17the17inspiratory17phase17of17each17respiratory17cycle.17These17sounds17are17
best17identified17as17-17ans-crackles17
Crackles,17which17are17sometimes17called17rales,17are17wet,17popping17sounds17creat
ed17by17air17moving17through17liquid17or17by17collapsed17alveoli17snapping17open17on
17inspiration.17They17are17most17common17at17the17end17of17inspiration.
When17performing17a17complete,17head-to-
toe17physical17examination,17which17physical-
assessment17technique17should17you17perform17first?17-17ans-Inspection17
Inspection17is17the17process17of17observation.17You17will17first17inspect17the17body17sy
stematically,17observing17for17normal17as17well17as17abnormal17physical17signs.17Whe
n17assessing17most17body17systems,17the17recommended17order17is17inspection,17pal
pation,17percussion,17and17auscultation.17Abdominal17assessment17is17an17exception,1
7since17any17manipulation17of17or17pressure17on17the17abdomen17may17stimulate17per
istalsis,17the17waves17of17contraction17that17propel17contents17through17the17gastrointe
stinal17tract,17and17thus17alter17the17patient's17bowel17sounds.17So,17when17assessing
17the17abdomen,17inspection17is17still17first,17but17auscultation17comes17before17percu
ssion17and17palpation.
What17is17your17primary17goal17in17performing17a17comprehensive17physical17assess
ment?17-17ans-To17develop17a17plan17of17care17
Remember17the17nursing17process:17assessment,17diagnosis,17planning,17implementat
ion,17evaluation.17Assessment17is17the17first17part17of17the17process.17It17generates17t
he17database17from17which17you17will17make17nursing17decisions.17Your17objective17in
17interacting17with17patients17is17to17identify17their17needs17and17concerns17and17help
17find17solutions.17That17is17the17nursing17process17in17action17-
17and17your17map17is17the17nursing17care17plan17you17establish17for17each17patient.17
Analyzing17and17synthesizing17data17will17provide17the17basis17for17each17nursing17dia
gnosis17and17for17the17selection17of17nursing17interventions17to17manage17actual17or17
potential17health17problems.
, While17performing17a17cardiovascular17assessment,17you17might17encounter17a17variet
y17of17pulsations17and17sounds.17Which17of17the17following17findings17is17considered17
normal?17-17ans-
A17brief17thump17felt17near17the17fourth17or17fifth17intercostal17space17near17the17left17
midclavicular17line
This17is17where17you17would17inspect17and17palpate17for17the17point17of17maximal17im
pulse.17Also17called17an17apical17pulsation,17it17occurs17as17the17apex17of17the17heart
17bumps17against17the17chest17wall17with17each17heartbeat.17The17apical17impulse17is
17not17always17visible17but17can17be17felt17as17a17brief17thump.17This17is17a17normal17
and17expected17finding17when17you17are17preparing17to17auscultate17an17apical17puls
e.
A17nurse17is17caring17for17a17group17of17clients.17Which17of17the17following17actions17
by17the17nurse17demonstrates17the17use17of17critical17thinking17skills?17-17ans-
Intervene17after17reviewing17arterial17blood17gas17results17for17a17client17who17is17on1
7mechanical17ventilation.
The17nurse17is17using17critical17thinking17when17analyzing17a17client's17critical17issues
17and17then17planning17to17intervene17with17an17appropriate17action.
A17nurse17is17following17the17steps17of17the17nursing17process17when17caring17for17a1
7group17of17clients.17Which17of17the17following17actions17by17the17nurse17demonstrate
s17the17evaluation17step17of17the17nursing17process?17-17ans-
Check17and17document17a17client's17pain17level173017min17after17administering17pain17
medication.
The17nurse17is17evaluating,17which17is17the17final17step17of17the17nursing17process,17t
o17determine17if17the17pain17medication17administered17to17the17client17is17effective.17
Evaluation17is17the17same17as17assessment;17however,17to17determine17the17client's17
status17and17progress,17evaluation17is17performed.
A17nurse17is17implementing17priority-
based17interventions17for17a17group17of17clients.17Which17of17the17following17clients17s
hould17the17nurse17see17first?17-17ans-
A17client17who17has17a17cast17on17a17compound17fracture17and17has17SaO217of1788%
When17using17the17airway,17breathing,17circulation17approach17to17client17care,17the17
nurse17should17determine17that17the17finding17of17SaO217of1788%17indicates17hypoxia
17and17requires17priority-based17interventions.
A17nurse17is17admitting17a17client17who17reports17increased17thirst17and17fatigue.17Whi
ch17of17the17following17actions17should17the17nurse17include17in17the17assessment17st
ep17of17the17nursing17process?17-17ans-
Ask17the17client17when17the17condition17started.
EXAM QUESTIONS AND CORRECT
DETAILED ANSWERS WITH
RATIONALES(VERIFIED ANSWERS)|
ALREADY GRADED A+
Over17which17abdominal17quadrant17are17bowel17sounds17most17active17and17therefor
e17easiest17to17auscultate?17-17ans-Right17lower17quadrant17
Over17which17abdominal17quadrant17are17bowel17sounds17most17active17and17therefor
e17easiest17to17auscultate?
As17part17of17your17general17patient17survey,17you17find17that17your17patient17has17a17
body17mass17index17(BMI)17of1723.17From17this17finding,17you17can17conclude17that17y
our17patient17-17ans-Has17body17mass17index17within17normal17limits17
BMI17is17a17measurement17of17an17adult's17body17fat17based17on17height17and17weigh
t.17Generally,17a17BMI17between1718.517and1724.917reflects17a17normal17weight17with1
7a17normal17amount17of17body17fat.17A17patient17with17a17BMI17below1718.517is17consi
dered17underweight;17a17patient17with17a17BMI17of172517or17above17is17considered17o
verweight;17and17one17with17a17BMI17of173017or17above17is17considered17obese.
While17performing17a17head-to-
toe17assessment,17you17perform17the17Romberg17test.17You17do17this17to17test17the17
patient's17-17ans-Balance17
The17most17common17test17of17balance17is17the17Romberg17test.17Ask17the17patient17t
o17stand17about17217feet17in17front17of17you,17with17her17feet17together,17toes17pointed
17forward,17and17her17hands17at17her17sides.17While17you17extend17your17hands17so17
that17one17is17on17either17side17of17the17patient,17ask17her17to17close17her17eyes.17W
atch17to17see17how17well17she17can17maintain17balance17in17that17position.17A17minim
um17of17swaying17is17normal,17but17if17the17patient17sways17more17than17a17couple17o
f17inches,17stop17the17test17and17document17that17the17patient17demonstrated17difficult
y17maintaining17balance17on17Romberg17testing.
When17using17and17maintaining17your17stethoscope,17it17is17important17to17-17ans-
Insert17the17earpieces17at17an17angle17toward17your17nose17
,Angling17the17earpieces17toward17your17nose17helps17ensure17that17sounds17are17effe
ctively17transmitted17to17your17eardrums.
You17are17performing17a17physical17examination17of17the17spine17for17an17older17adult
.17Which17of17the17following17findings17is17common17with17aging?17-17ans-Kyphosis17
Kyphosis,17a17pronounced17"hunchback"17curvature17of17the17spine,17is17an17abnorma
l17angulation17of17the17posterior17curve17of17the17thoracic17spine,17usually17a17result17
of17osteoporosis.17It17is17most17common17in17older17adults17and17tends17to17increase1
7with17aging.17This17pronounced17convexity17of17the17thoracic17spine17is17also17comm
on17in17older17patients17who17have17had17vertebral17fractures.
When17performing17a17respiratory17assessment,17you17auscultate17wet,17popping17sou
nds17at17the17inspiratory17phase17of17each17respiratory17cycle.17These17sounds17are17
best17identified17as17-17ans-crackles17
Crackles,17which17are17sometimes17called17rales,17are17wet,17popping17sounds17creat
ed17by17air17moving17through17liquid17or17by17collapsed17alveoli17snapping17open17on
17inspiration.17They17are17most17common17at17the17end17of17inspiration.
When17performing17a17complete,17head-to-
toe17physical17examination,17which17physical-
assessment17technique17should17you17perform17first?17-17ans-Inspection17
Inspection17is17the17process17of17observation.17You17will17first17inspect17the17body17sy
stematically,17observing17for17normal17as17well17as17abnormal17physical17signs.17Whe
n17assessing17most17body17systems,17the17recommended17order17is17inspection,17pal
pation,17percussion,17and17auscultation.17Abdominal17assessment17is17an17exception,1
7since17any17manipulation17of17or17pressure17on17the17abdomen17may17stimulate17per
istalsis,17the17waves17of17contraction17that17propel17contents17through17the17gastrointe
stinal17tract,17and17thus17alter17the17patient's17bowel17sounds.17So,17when17assessing
17the17abdomen,17inspection17is17still17first,17but17auscultation17comes17before17percu
ssion17and17palpation.
What17is17your17primary17goal17in17performing17a17comprehensive17physical17assess
ment?17-17ans-To17develop17a17plan17of17care17
Remember17the17nursing17process:17assessment,17diagnosis,17planning,17implementat
ion,17evaluation.17Assessment17is17the17first17part17of17the17process.17It17generates17t
he17database17from17which17you17will17make17nursing17decisions.17Your17objective17in
17interacting17with17patients17is17to17identify17their17needs17and17concerns17and17help
17find17solutions.17That17is17the17nursing17process17in17action17-
17and17your17map17is17the17nursing17care17plan17you17establish17for17each17patient.17
Analyzing17and17synthesizing17data17will17provide17the17basis17for17each17nursing17dia
gnosis17and17for17the17selection17of17nursing17interventions17to17manage17actual17or17
potential17health17problems.
, While17performing17a17cardiovascular17assessment,17you17might17encounter17a17variet
y17of17pulsations17and17sounds.17Which17of17the17following17findings17is17considered17
normal?17-17ans-
A17brief17thump17felt17near17the17fourth17or17fifth17intercostal17space17near17the17left17
midclavicular17line
This17is17where17you17would17inspect17and17palpate17for17the17point17of17maximal17im
pulse.17Also17called17an17apical17pulsation,17it17occurs17as17the17apex17of17the17heart
17bumps17against17the17chest17wall17with17each17heartbeat.17The17apical17impulse17is
17not17always17visible17but17can17be17felt17as17a17brief17thump.17This17is17a17normal17
and17expected17finding17when17you17are17preparing17to17auscultate17an17apical17puls
e.
A17nurse17is17caring17for17a17group17of17clients.17Which17of17the17following17actions17
by17the17nurse17demonstrates17the17use17of17critical17thinking17skills?17-17ans-
Intervene17after17reviewing17arterial17blood17gas17results17for17a17client17who17is17on1
7mechanical17ventilation.
The17nurse17is17using17critical17thinking17when17analyzing17a17client's17critical17issues
17and17then17planning17to17intervene17with17an17appropriate17action.
A17nurse17is17following17the17steps17of17the17nursing17process17when17caring17for17a1
7group17of17clients.17Which17of17the17following17actions17by17the17nurse17demonstrate
s17the17evaluation17step17of17the17nursing17process?17-17ans-
Check17and17document17a17client's17pain17level173017min17after17administering17pain17
medication.
The17nurse17is17evaluating,17which17is17the17final17step17of17the17nursing17process,17t
o17determine17if17the17pain17medication17administered17to17the17client17is17effective.17
Evaluation17is17the17same17as17assessment;17however,17to17determine17the17client's17
status17and17progress,17evaluation17is17performed.
A17nurse17is17implementing17priority-
based17interventions17for17a17group17of17clients.17Which17of17the17following17clients17s
hould17the17nurse17see17first?17-17ans-
A17client17who17has17a17cast17on17a17compound17fracture17and17has17SaO217of1788%
When17using17the17airway,17breathing,17circulation17approach17to17client17care,17the17
nurse17should17determine17that17the17finding17of17SaO217of1788%17indicates17hypoxia
17and17requires17priority-based17interventions.
A17nurse17is17admitting17a17client17who17reports17increased17thirst17and17fatigue.17Whi
ch17of17the17following17actions17should17the17nurse17include17in17the17assessment17st
ep17of17the17nursing17process?17-17ans-
Ask17the17client17when17the17condition17started.
