NCLEX-RN
NCLEX RN Health Promotion and Maintenance Practice Questions Questions
Question 1 of 5
The nurse reviews the pattern of a nonstress test performed on a pregnant client and interprets the finding as which result? (Refer to figure.)
Correct Answer: A
Rationale: A nonstress test assesses fetal well-being and evaluates the ability of the fetal heart to accelerate, often in association with fetal movement. Accelerations of the fetal heart rate are associated with adequate oxygenation, a healthy neural pathway, and the fetal heart's ability to respond to stimuli. A reactive test is described as at least two fetal heart rate accelerations, with or without fetal movement, occurring within a 20-minute period and peaking at least 15 beats/minute above the baseline and lasting 15 seconds from baseline to baseline. This recording (see figure) identifies a reactive nonstress test. The fetal heart rate acceleration peaks at least 15 beats/minute and lasts for at least 15 seconds in response to fetal movement. A nonreactive test is an abnormal or nonreassuring test. In a nonreactive test, the recording does not demonstrate the required characteristics of a reactive test within a 40-minute period.
Question 2 of 5
The nurse is caring for a client with morning sickness who is 8 weeks pregnant with her first child. What should the nurse advise the client to do to manage nausea?
Correct Answer: C
Rationale: Consuming fluids early avoids triggering nausea later. Protein-heavy meals, spicy foods, or brushing teeth post-eating may worsen nausea.
Question 3 of 5
The nurse is reviewing home care instructions with a client who has been diagnosed with type 1 diabetes mellitus and has a history of diabetic ketoacidosis (DKA). The client's spouse is present when the instructions are given. Which statement by the spouse indicates that further teaching is necessary?
Correct Answer: A
Rationale: Diabetic ketoacidosis (DK
A) is a life-threatening complication of type 1 diabetes mellitus that develops when a severe insulin deficiency occurs. Infection and the stopping of insulin are precipitating factors for DKA. Nausea and abdominal pain that last more than 1 or 2 days need to be reported to the primary health care provider because these signs/symptoms may be indicative of DKA. Withholding insulin during vomiting can exacerbate DKA and is incorrect.
Question 4 of 5
The nurse determines that the client with atherosclerosis understands dietary modifications to lower the risk of heart disease if which food selection is made?
Correct Answer: B
Rationale:
To lower the risk of heart disease, the diet should be low in saturated fat with the appropriate number of total calories. The diet should include less red meat (roast beef, cheeseburger) and more white meat with the skin removed. Dairy products used should be low in fat, and foods with high amounts of empty calories (white gravy) should be avoided.
Question 5 of 5
The nurse is percussing the anterior thorax and the abdomen for tones and expects to note dullness in which anatomic location? (Refer to figure.)
Correct Answer: C
Rationale: Percussion involves tapping the body with the fingertips to set the underlying structures in motion and thus produce a sound. Dullness will be noted over the liver, located in the upper right quadrant of the abdomen and beneath the lower ribs on the right side. Tympany is the most common percussion tone heard in the abdomen and is caused by the presence of gas. Resonance is the percussion tone heard between the ribs.