NCLEX-PN
Health Promotion and Maintenance NCLEX PN Questions Questions
Question 1 of 5
A client is brought to the emergency department after a motor vehicle accident. The client is alert and cooperative but has sustained multiple fractures of the legs. How should the nurse proceed with data collection?
Correct Answer: B
Rationale: When a client is alert and cooperative but has sustained multiple fractures, the nurse should prioritize obtaining health history information while performing the examination and initiating emergency measures. This approach allows the nurse to gather essential information without delaying immediate interventions. Option A is incorrect because collecting health history information before addressing the immediate need for treatment may lead to a delay in necessary interventions. Option C is incorrect as it includes non-urgent aspects of data collection that are not a priority in this critical situation. Option D is incorrect because delaying health history questions until after treating the fractures may result in missing crucial information essential for the client's immediate care.
Question 2 of 5
A nurse is auscultating for vesicular breath sounds in a client. Of which quality would the nurse expect these normal breath sounds to be?
Correct Answer: D
Rationale: The correct answer is D: 'Rustling.' Vesicular breath sounds are described as rustling and resemble the sound of wind blowing through trees. Harsh, hollow, and tubular sounds are associated with bronchial (tracheal) breath sounds, not vesicular breath sounds. Harsh sounds are high-pitched, hollow sounds are reverberating, and tubular sounds are like blowing air into a tube.
Therefore, options A, B, and C are incorrect descriptions of vesicular breath sounds and are more characteristic of bronchial breath sounds.
Question 3 of 5
A nurse palpates a client’s radial pulse, noting the rate, rhythm, and force, and concludes that the client’s pulse is normal. Which notation would the nurse make in the client’s record to document the force of the client’s pulse?
Correct Answer: C
Rationale: When assessing a pulse, the nurse should note the rhythm, amplitude, and symmetry of pulses and should compare peripheral pulses on the two sides for rate, rhythm, and quality. A 4-point scale may be used to assess the force (amplitude) of the pulse: 4+ for a bounding pulse, 3+ for an increased pulse, 2+ for a normal pulse, and 1+ for a weak pulse. In this case, the nurse would grade the client’s pulse as 2+ based on the description of a normal pulse.
Therefore, the correct notation for the force of the client’s pulse is '2+' as it indicates a normal pulse.
Choices A, B, and D are incorrect as they represent different levels of pulse force that do not align with the description given in the scenario.
Question 4 of 5
At a health screening clinic, a nurse is educating a young woman about breast self-examination (BSE). The nurse determines that the client demonstrates understanding when she makes which statement?
Correct Answer: D
Rationale: The correct answer is 'Monthly BSE includes inspection before a mirror and palpation both in the shower and while lying down.' BSE should be performed monthly after the menstrual period, not every other month or on the day menstruation begins. Performing BSE on the seventh day of the menstrual cycle when the breasts are smallest and least congested is recommended. While BSE is a useful tool for early detection, it is not the only method. Regular physical examinations and mammograms are also important. The correct technique for BSE includes inspecting the breasts in front of a mirror, palpating in the shower for easier detection, and conducting palpation while lying down for thorough examination.
Question 5 of 5
A nurse assisting with data collection uses the back of the hand to feel the client's skin on both arms and notes that the skin is warm. The nurse makes which determination?
Correct Answer: B
Rationale:
To assess skin temperature, the nurse would first note the temperature of their own hands.
Then, using the backs of the hands to palpate the client's skin bilaterally, warmth suggests normal circulatory status if the skin is warm and the temperature is equal bilaterally. The hands and feet may feel slightly cooler in a cool environment. Options A, C, and D are incorrect responses. A warm skin temperature does not indicate a fever, the need for additional fluids, or the need to have the blanket removed.