NCLEX-RN
Health Promotion and Maintenance NCLEX RN Questions Questions
Extract:
Question 1 of 5
A client is being discharged from the hospital to home with an indwelling urinary catheter after the surgical repair of the bladder after trauma. The nurse determines that the client understands the principles of catheter management to prevent complications if the client states to follow which instruction?
Correct Answer: B
Rationale: Keeping the drainage bag lower than the bladder prevents urine backflow, reducing infection risk. The perineal area should be cleansed twice daily and after bowel movements. Adequate fluid intake is necessary to prevent infection, and coiling tubing under the thigh can obstruct drainage.
Question 2 of 5
A nurse is caring for a client who is post-op day #1 after a total hip replacement. Although the client was alert with a normal affect in the morning, by lunchtime, the nurse notes the client is confused, has slurred speech, and is having trouble with her balance. Her blood glucose level is 48 mg/dl. What is the next action of the nurse?
Correct Answer: D
Rationale: A client with a blood glucose level of 48 mg/dl is experiencing significant hypoglycemia, as manifested by confusion, balance difficulties, and slurred speech. The nurse should work to correct this situation as rapidly as possible. The first measure that can be performed quickly and will have fast results is to give the client something to eat or drink that contains glucose, such as 6 oz. of orange juice. Administering a bolus of D20W through the IV (
Choice
B) would be too aggressive and could lead to complications in this scenario. Administering regular insulin (
Choice
C) would further lower the blood glucose level, worsening the client's symptoms. Contacting the physician (
Choice
A) is important, but immediate intervention to raise the blood glucose level is crucial to address the client's hypoglycemia.
Question 3 of 5
A nurse is assessing a client's pulse oximetry on the surgical unit. As part of routine interventions, the nurse turns off the exam light over the client's bed. Which of the following best describes the rationale for this intervention?
Correct Answer: A
Rationale: When assessing a client's pulse oximetry values, the nurse should turn off any extra environmental lights that are unnecessary, including exam lights or over-bed lights. External light sources may cause falsely high oximetry values when the extra light interferes with the sensor of the oximeter, leading to inaccurate readings.
Choice B is incorrect because a bright light in the client's face would not directly affect the pulse oximetry values.
Choice C is incorrect as external light sources typically cause falsely high, not low, oximetry values.
Choice D is incorrect as the primary reason for turning off the light is to prevent falsely high readings, not solely for the client's comfort.
Question 4 of 5
The nurse has taught a client with a below-the-knee amputation about home care and about monitoring for and preventing complications related to prosthesis and residual limb care. The nurse determines that the client has understood the instructions if the client stated that which action should be taken?
Correct Answer: B
Rationale: The client should inspect all surfaces of the residual limb daily for irritation, blisters, and breakdown. The client should wear a clean woolen (not nylon) sock each day. The residual limb is cleansed daily with a gentle soap and water and dried carefully. Alcohol is avoided because it could cause drying or cracking of the skin. Oils and creams are also avoided because they are too softening to the skin for safe prosthesis use.
Question 5 of 5
The nurse instructs a client with mild preeclampsia about home care measures. Which statement by the client indicates to the nurse that the teaching has been effective concerning the assessment of complications for preeclampsia?
Correct Answer: C
Rationale: Classic signs of preeclampsia include hypertension and proteinuria. The client diagnosed with preeclampsia needs to be instructed to report any increases in blood pressure; 2+ proteinuria; weight gain of more than 1 pound per week; the presence of edema in the face, hands, and sacral area; and decreased fetal activity to the primary health care provider immediately to prevent worsening of the preeclamptic condition. The weight needs to be checked at the same time each day, after voiding, before breakfast, and with the client wearing the same clothes in order to obtain reliable weight readings. Blood pressure measurements need to be taken in the same arm every day in a sitting position to obtain consistent and accurate readings. It is important to keep primary health care provider appointments even if the client is receiving visits from a home care nurse.