NCLEX-RN
Health Promotion and Maintenance NCLEX RN Questions Questions
Question 1 of 5
While caring for a client in labor, a nurse attaches an electronic fetal monitor to the client's abdomen to assess the baby's heart rate. The nurse observes that the baby's heart rate slows down during each contraction and does not return to normal limits until after the contraction is complete. What type of fetal heart rate change does this pattern describe?
Correct Answer: B
Rationale: Late decelerations are characterized by the baby's heart rate declining in utero during contractions. The heart rate drops below baseline and stays low until after the contraction ends. Late decelerations are concerning as they indicate uteroplacental insufficiency, which can compromise fetal oxygenation. This pattern is a non-reassuring sign and requires immediate intervention. Variable decelerations are typically abrupt decreases in heart rate, often associated with cord compression. Early decelerations, on the other hand, mirror the contractions and are considered benign, resulting from fetal head compression. Accelerations are reassuring signs of fetal well-being, indicating a responsive and healthy fetal nervous system.
Question 2 of 5
A nurse is assisting a pregnant client who is having an amniocentesis. Which of the following statements by the nurse indicates the correct teaching for this procedure?
Correct Answer: D
Rationale: An amniocentesis is performed to draw amniotic luid
from the sac around the fetus during pregnancy. It may be analyzed for
certain disorders or complications associated with pregnancy.
Following the procedure, the nurse should wash the client's abdomen
and place a small bandage over the puncture site
Question 3 of 5
A nurse is assessing a client's pulse oximetry on the surgical unit. As part of routine interventions, the nurse turns off the exam light over the client's bed. Which of the following best describes the rationale for this intervention?
Correct Answer: A
Rationale: When assessing a client's pulse oximetry values, the nurse should turn off any extra environmental lights that are unnecessary, including exam lights or over-bed lights. External light sources may cause falsely high oximetry values when the extra light interferes with the sensor of the oximeter, leading to inaccurate readings.
Choice B is incorrect because a bright light in the client's face would not directly affect the pulse oximetry values.
Choice C is incorrect as external light sources typically cause falsely high, not low, oximetry values.
Choice D is incorrect as the primary reason for turning off the light is to prevent falsely high readings, not solely for the client's comfort.
Question 4 of 5
Mrs. M has had diabetes for seven years. She has worked hard to control her blood glucose levels and watch her dietary intake. Her physician orders a hemoglobin A1C test. Which of the following best describes the action of this test?
Correct Answer: D
Rationale: A hemoglobin A1C test, also known as a glycated hemoglobin test, determines the amount of hemoglobin that is coated with glucose. Excess glucose in the bloodstream may cause it to attach to hemoglobin on red blood cells. Because the life of these cells is between 2 and 3 months, the hemoglobin A1C is an accurate measurement of a client's glucose during that time.
Choices A, B, and C are incorrect.
Choice A relates to anemia and iron supplements, which are not assessed by a hemoglobin A1C test.
Choice B mentions excess glucose in the urine, which is typically assessed through a urine glucose test, not the hemoglobin A1C test.
Choice C is incorrect as the test is not related to the amount of hemoglobin reaching the liver to support gluconeogenesis; instead, it specifically measures the amount of hemoglobin that is glycated or coated with glucose.
Question 5 of 5
A client with a broken femur is in a traction splint in bed. Which of the following interventions is NOT part of caring for this client?
Correct Answer: C
Rationale: When caring for a client with a broken femur in a traction splint, turning the client to a side-lying position is not recommended. This client is at risk of skin breakdown and complications due to the injury, making it important to prevent unnecessary movement that may increase the risk of injury or discomfort. Palpating the temperature of both feet helps in assessing circulation, evaluating pulses bilaterally ensures perfusion to the extremities, and relieving heel pressure by placing a pillow under the foot helps in reducing pressure points and preventing complications like pressure ulcers.
Therefore, the correct answer is turning the client to a side-lying position as it is not a recommended intervention in this scenario.