NCLEX-PN
Health Promotion and Maintenance NCLEX PN Questions Questions
Question 1 of 5
When performing the confrontation test to assess peripheral vision, what action should the nurse take?
Correct Answer: D
Rationale: When performing the confrontation test to assess peripheral vision, the nurse should position at eye level with the client, cover one eye, and have the client cover the opposite eye. This approach allows the examiner to bring a small object into the visual field to evaluate the client's peripheral vision. The test aims to compare the client's peripheral vision with the examiner's vision to identify any visual field deficits.
Choices A, B, and C are incorrect.
Choice A pertains to testing color vision, which is not part of the confrontation test.
Choice B describes a different procedure that involves advancing a target midline between the client and examiner, not the correct approach for the confrontation test.
Choice C is inaccurate as it fails to include the essential step of positioning at eye level with the client, making it an incorrect representation of the confrontation test.
Question 2 of 5
A community health nurse is instructing a group of female clients about breast self-examination (BSE). The nurse instructs the clients to perform the examination in which manner?
Correct Answer: D
Rationale: Breast self-examination (BSE) should be performed after the menstrual period, specifically on the seventh day of the menstrual cycle, when the breasts are smallest and least congested. This timing facilitates the easier detection of any abnormalities. Performing BSE at the onset of menstruation (Option
A) can lead to false results due to hormonal changes affecting breast tissue. Performing it every month during ovulation (Option
B) is not recommended as breast tissue may be more tender and lumpy during this time. Conducting weekly examinations at the same time of day (Option
C) is unnecessary and can lead to unnecessary anxiety for the client.
Question 3 of 5
An allergic reaction is classified as what type of pharmacological effect?
Correct Answer: C
Rationale: An allergic reaction is classified as an adverse effect because it is an unintended response to a medication that requires treatment. A side effect is an undesired but somewhat expected reaction to a drug that does not necessarily need intervention. Incompatibility refers to an unsuitable combination of substances that leads to an adverse effect. A therapeutic effect is the desired and intended outcome of a medication.
Question 4 of 5
A healthcare professional reviewing the health care record of a client notes documentation of grade 4 muscle strength. The healthcare professional understands that this indicates:
Correct Answer: D
Rationale: Muscle strength is graded on a scale of 0 to 5. A grade of 5 indicates normal strength and is described as full ROM against gravity with full resistance. Grade 4 indicates good strength and full ROM against gravity with some resistance. Grade 3 indicates fair strength and full ROM with gravity. Grade 2 indicates poor strength and full ROM with gravity eliminated (passive motion). Grade 1 indicates trace strength and slight contraction. Grade 0 indicates zero strength and no contraction.
Therefore, the correct answer is 'Full ROM against gravity with some resistance.'
Choices A, B, and C are incorrect as they do not match the description of muscle strength associated with a grade of 4.
Question 5 of 5
Which of the following actions should the LPN perform for a client with an active digoxin IV order? Select all that apply.
Correct Answer: D
Rationale: The correct actions for the LPN to perform for a client with an active digoxin IV order are to monitor ECG rhythm throughout administration and monitor the client's pulse for 1 minute prior to administration. These actions are crucial as digoxin affects the heart's electrical activity, and it should not be administered if the client's pulse is less than 60 bpm. Monitoring respirations and blood pressure are not directly associated with digoxin administration. Administering IV medications is typically outside the LPN's scope of practice.