NCLEX-PN
Health Promotion and Maintenance NCLEX PN Questions Questions
Extract:
Question 1 of 5
A 64 year-old male who has been diagnosed with COPD and CHF exhibits an increase in total body weight of 10 lbs. over the last few days. The nurse should:
Correct Answer: B
Rationale: Checking the intake and output prior to making any decisions about patient care helps determine if the weight gain is due to fluid retention, a common issue in CHF.
Question 2 of 5
When a client who is 25 years of age asks the nurse when she should seek fertility counseling, the best response by the nurse is:
Correct Answer: D
Rationale: The guidelines for a fertility workup are to refer after the couple has not conceived after one year of unprotected intercourse. So,
Choice 1 is technically correct, but it doesn't consider the immediate need for the couple to have some counseling.
Choice 4 is the best answer because it gives the couple guidance now and the referral at the appropriate time. If the woman is over the age of 35, an earlier referral, at six to nine months of unprotected intercourse, is appropriate. It is true that the average time it takes a 25-year-old woman to conceive is 5.3 months, but that does not address the concern the client is expressing.
Choice 4 is still the most caring and correct answer. Couples conceive within the first month of unprotected intercourse 20% of the time.
Question 3 of 5
The LPN participates in a home visit for a client with Type 2 Diabetes who has been taking Metformin for 3 years. The client states that for the past 3 months, they have been trying a vegan diet and experiencing fatigue, confusion, and mood changes. What is a likely cause of the new symptoms?
Correct Answer: A
Rationale: The correct answer is vitamin B12 deficiency. Long-term use of Metformin can lead to vitamin B12 deficiency, and a vegan diet is low in vitamin B12. Symptoms of vitamin B12 deficiency include anemia, fatigue, confusion, and mood changes. Chronic hypoglycemia is unlikely in a client with Type 2 Diabetes who has been taking Metformin as it typically causes hyperglycemia. Vitamin D deficiency usually presents with symptoms related to bones and muscles, not confusion and mood changes. Increased tolerance to Metformin does not explain the client's new symptoms, which are more indicative of a nutritional deficiency like vitamin B12.
Question 4 of 5
The LPN needs to determine the client's respiratory rate. What is the best technique to do this?
Correct Answer: D
Rationale: The best technique to determine a client's respiratory rate is to count respirations while pretending to check the client's pulse. You should not inform the client that you are counting their respirations, as this might lead to a change in their breathing pattern. Pretending to check the pulse allows you to be close to the client without revealing that you are assessing their respiratory rate. Asking the client to sit still may not be as effective, as it may cause them to concentrate on their breathing. Watching from across the room may not provide an accurate assessment of respirations, as they might be difficult to observe.
Question 5 of 5
While assisting with data collection on a client, a nurse hears a bruit over the abdominal aorta. What action should the nurse prioritize based on this finding?
Correct Answer: C
Rationale: Detection of a bruit over the aorta during abdominal assessment may indicate the presence of an aneurysm. The nurse's priority action should be to notify the healthcare provider to further evaluate the situation. Palpating the area or percussing the abdomen could potentially increase the risk of an aneurysm rupture. While documenting the finding is important, the priority is to ensure timely intervention by involving the healthcare provider.