- | P a g e
NCLEX PN Actual Exam Test Bank Newest 2025/2026 With Complete 500+ Questions And Correct Answers |Already Graded A+||Newest Version!!!|
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.
- / 4
- | P a g e
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.
- / 4
- | P a g e
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.
- / 4
- | P a g e
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
- / 4