NCLEX-PN
Health Promotion and Maintenance NCLEX PN Questions
Extract:
Question 1 of 5
A client has just returned from surgery where a femoral-popliteal bypass was performed. The nurse has assessed the client and is unable to feel a pulse at either the dorsalis pedis or the posterior tibial sites of the left foot. The foot feels warm and the color is pink. What action should the nurse perform next to prevent ischemia?
Correct Answer: B
Rationale: The nurse should immediately obtain a Doppler device and recheck the pulses. The dorsalis pedis and posterior tibial can be difficult to assess and might need to be verified with a Doppler. Because the client just had a surgery in which a complication is arterial insufficiency, the client must be monitored carefully. If the pulses are not found, the nurse should recognize that this is an emergent situation, and the physician must be notified immediately. If the nurse waits 30 minutes before determining if the pulses can be felt, this could compromise the viability of the client's foot due to ischemia. Documenting the findings is important but must be performed after the nurse locates the dorsalis pedis and posterior tibial pulses or any necessary interventions are made.
Question 2 of 5
When a client with a major burn experiences body image disturbance, which of the following is an appropriate nursing intervention classification?
Correct Answer: A
Rationale: Grief work facilitation helps address body image disturbance in burn clients by supporting grief resolution related to altered appearance.
Question 3 of 5
A client is given an opiate drug for pain relief following general anesthesia. The client becomes extremely somnolent with respiratory depression. The physician is likely to order the administration of:
Correct Answer: A
Rationale: Naloxone reverses opioid-induced respiratory depression and somnolence by antagonizing opioid receptors. The other drugs do not address opioid overdose.
Question 4 of 5
A client is given an opiate drug for pain relief following general anesthesia. The client becomes extremely somnolent with respiratory depression. The physician is likely to order the administration of:
Correct Answer: A
Rationale: Naloxone is an opiate antagonist. It attaches to opiate receptors and blocks or reverses the action of narcotic analgesics.
Choice 2 is incorrect because Labetalol is a beta blocker.
Choice 3 is incorrect because Neostigmine is an anticholinesterase agent.
Choice 4 is incorrect because Thiothixene is an antipsychotic agent.
Question 5 of 5
Chemotherapeutic agents often produce a degree of myelosuppression including leukopenia. Leukopenia does not present immediately but is delayed several days or weeks because:
Correct Answer: D
Rationale: Time is required to clear circulating cells before the effect that chemotherapeutic drugs have on precursor cell maturation in the bone marrow becomes evident.