NCLEX-PN
Health Promotion and Maintenance NCLEX PN Questions Questions
Question 1 of 5
A nurse is preparing to measure a client's calf circumference. The nurse performs this procedure by performing which action?
Correct Answer: A
Rationale:
To measure a client's calf circumference accurately, a nurse should place a non-stretchable tape measure around the widest point of the lower leg. It is crucial to ensure that the tape measure is positioned at the same number of centimeters down from a specific landmark, such as the patella, on both legs for consistency. Placing the tape measure 2 inches above the knee (Option
B), 2 inches above the ankle (Option
C), or 2 inches below the patella (Option
D) would not provide an accurate measurement of the calf circumference.
Therefore, these options are incorrect choices.
Question 2 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.
Question 3 of 5
The client is being discharged with a prescription for an inhaled glucocorticoid for asthma. Which of the following statements indicates additional education is needed prior to discharge?
Correct Answer: B
Rationale: The correct answer is, 'I will wait five minutes after taking this medication and then gargle water.' After using an inhaled glucocorticoid, it is essential to wait for 5 minutes and then gargle water to remove any residue from the mouth, which can reduce the risk of developing thrush, a fungal infection.
Choice A is correct as holding the breath for 10 seconds after each puff helps the medication reach deep into the lungs.
Choice C is also correct as waiting at least one minute between puffs ensures proper delivery of the medication.
Choice D is incorrect because it is important to take the medication daily as prescribed to control asthma symptoms, even if the person is not experiencing any at that moment.
Question 4 of 5
A nurse assisting with data collection notes that the client exhibits rapid, involuntary oscillating movements of the eyeball when looking at the nurse. The nurse documents this finding using which term?
Correct Answer: B
Rationale: When a nurse observes rapid, involuntary oscillating movements of the eyeball in a client, this is described as nystagmus. Nystagmus appears as a fine oscillating movement, most notable around the iris. It is important to assess for nystagmus when evaluating ocular muscle weakness. Mild nystagmus at extreme lateral gaze is considered normal; nystagmus in any other position is not. Ptosis refers to a drooping of the eyelid, not rapid eye movements. Scleral icterus is the yellowing of the sclera up to the cornea, indicating jaundice, not related to eye movements. Exophthalmos is a noticeable protrusion of the eyeball, typically seen in hyperthyroidism, not associated with rapid oscillating eye movements.
Question 5 of 5
A healthcare professional is using an otoscope to inspect the ears of an adult client. Which action does the professional take before inserting the otoscope?
Correct Answer: A
Rationale: In an adult client, the healthcare professional should pull the pinna up and back before inserting the otoscope. This action helps straighten the S shape of the ear canal, making it easier to insert the otoscope directly and comfortably. Tipping the client's head down and toward or away from the examiner is not the correct action when using an otoscope in an adult. Pulling the pinna down and forward is typically done when examining an infant or a child younger than 3 years old to straighten their ear canal for better visualization.