NCLEX-PN
NCLEX Health Promotion and Maintenance Questions
Question 1 of 5
A client can receive the mumps, measles, rubella (MMR) vaccine if he or she:
Correct Answer: D
Rationale: A simple cold without fever does not preclude vaccination.
Choices 1 and 2 are incorrect because pregnant women and immunocompromised individuals cannot have the MMR vaccine because the rubella component is a live virus and might cause birth defects and/or disease.
Choice 3 is incorrect because the American Academy of Pediatrics states, 'Persons who have experienced anaphylactic reactions to topically or systemically administered neomycin should not receive measles vaccine.'
Question 2 of 5
A day care center has asked the nurse to provide education for parents regarding safety in the home. What type of preventive care does this represent?
Correct Answer: A
Rationale: Primary prevention involves activities that are utilized to promote wellness or prevent illness or injury. There are many dangers in the home for small children. Providing education regarding the need for safety measures to prevent injury in the home is considered primary prevention. Secondary prevention involves early detection of a disease or illness and quick intervention to aid the client in maintenance of the disease or injury. Tertiary prevention involves the reduction of a disability and the promotion of the highest level of functioning for a client in relation to his or her disease or injury. Health promotion is any activity that increases a client's health and wellness.
Question 3 of 5
A teenage client is admitted to the hospital because of acetaminophen (Tylenol) overdose. Overdoses of acetaminophen can precipitate life-threatening abnormalities in which of the following organs?
Correct Answer: B
Rationale: Acetaminophen is extensively metabolized in the liver.
Choices A, C, and D are incorrect because prolonged use of acetaminophen might result in an increased risk of renal dysfunction, but a single overdose does not precipitate life-threatening problems in the respiratory system, renal system, or adrenal glands.
Question 4 of 5
A nurse doing a home health visit consults with a male patient that has a diagnosis of CAD and COPD. The patient is currently taking Ventolin, Azmacort, Aspirin, and Theophylline. The patient complains of upset stomach, nausea and feeling uncomfortable. The nurse should:
Correct Answer: A
Rationale: Consult the physician immediately, due to the fact that theophylline toxicity may be occurring.
Question 5 of 5
When teaching a woman about possible side effects of hormone replacement therapy, the nurse should include information about all of the following except:
Correct Answer: A
Rationale: When taking estrogen, there is an increased risk of diabetes or hyperglycemia due to lowered glucose tolerance. It is true that monthly menses might return when taking combination hormones. The progestin is responsible for this. There is also a risk of gallbladder disease. It is also true that there is an increased risk of breast, cervical, and ovarian cancer with long-term hormone replacement therapy.