NCLEX-RN
Health Promotion and Maintenance NCLEX RN Questions Questions
Question 1 of 5
A client with hyperkalemia may exhibit peaked T waves on an electrocardiogram. This manifestation is an early sign of high potassium levels, but the diagnosis should not be based on this aspect alone. Untreated, hyperkalemia can lead to progressively worsening cardiac instability.
Correct Answer: B
Rationale: A lumbar puncture is performed to obtain cerebrospinal fluid for analysis to investigate various conditions affecting the client. During the procedure, the client is typically positioned on their side or sitting leaning over a table with their back rounded. The physician inserts a needle into the back around the L4-L5 vertebrae to collect the sample. Option A is incorrect because a lumbar puncture does not draw blood but instead collects cerebrospinal fluid. Option C is incorrect as the client should not necessarily lie flat for 24 hours post-procedure. Option D is incorrect as the common risks of a lumbar puncture include headache, back pain, and potential infection, not nausea, rash, or hypotension.
Question 2 of 5
A client diagnosed with acquired immunodeficiency syndrome (AIDS) gets recurrent Candida infections of the mouth (thrush). The nurse has given the client instructions to minimize the occurrence of thrush and determines that the client understands the instructions if which statement is made by the client?
Correct Answer: B
Rationale:
To minimize the occurrence of oral thrush in a client with AIDS, maintaining good oral hygiene is essential. Rinsing the mouth with warm saline or water helps keep the oral cavity clean and reduces the risk of Candida overgrowth. Using mouthwash once a week is insufficient, and brushing only once a day does not provide adequate oral hygiene. Increasing red meat intake does not directly affect thrush prevention, as dietary changes unrelated to sugar or carbohydrate reduction have little impact on Candida infections.
Question 3 of 5
Which nursing intervention is most appropriate to maintain the patency of a client's nasogastric tube?
Correct Answer: B
Rationale: The correct answer is to irrigate the tube as per physician's order. A client with a nasogastric tube is at risk of the tube kinking or clotting off, which can lead to complications such as abdominal distention or vomiting.
To ensure the patency of the tube, the nurse should follow the physician's orders and facility policy to irrigate the tube with water or a solution as needed. Maintaining a constant connection to low-intermittent suction (
Choice
A) is not typically done to maintain tube patency. Suctioning the mouth and nose every shift (
Choice
C) is not directly related to maintaining nasogastric tube patency. Performing a daily fecal occult blood sample (
Choice
D) is unrelated to maintaining the patency of a nasogastric tube.
Question 4 of 5
A client returns from surgery after having a colon resection. The nurse is performing an assessment and notes the wound edges have separated. This condition is called:
Correct Answer: C
Rationale: Wound dehiscence occurs when the edges of a wound pull apart. The condition may occur following a surgical procedure if the sutures were deficient. Wound dehiscence may also occur following a wound infection or in cases where a client significantly stretches or overuses the associated tissues. Evisceration refers to the protrusion of internal organs through an open wound. Hematoma is a localized collection of blood outside the blood vessels. Granulation is the formation of new connective tissue and tiny blood vessels on the surface of a wound during the healing process.
Question 5 of 5
A patient with bipolar disorder asks the nurse, "Why did I get this illness? I don't want to be sick."? The nurse would best respond with:
Correct Answer: D
Rationale: The correct response is, 'We don't fully understand the cause, but mental illnesses do seem to run in the family.' Current research suggests that while genetics play a role in the development of mental illnesses like bipolar disorder, it is not the sole factor. Environmental influences, life experiences, and other non-genetic factors also contribute significantly to the manifestation of mental disorders.
Choices A, B, and C provide incorrect information that is not supported by current research. Traumatic childhood experiences, contracting a virus during childhood, and an overactive immune system are not established causes of bipolar disorder or mental illnesses in general.