NCLEX-RN
Health Promotion and Maintenance NCLEX RN Questions Questions
Extract:
Question 1 of 5
A client is being monitored for decreased tissue perfusion and increased risk of skin breakdown. Which measure best improves tissue perfusion in this client?
Correct Answer: B
Rationale: For a client at risk of impaired skin integrity due to decreased tissue perfusion, improving mobility is crucial to enhance tissue perfusion and prevent skin breakdown. Range of motion exercises are beneficial to increase circulation and prevent complications. Massaging reddened areas may further damage fragile skin. Administering antithrombotics may be necessary for specific conditions but does not directly address tissue perfusion. Feeding a high-carbohydrate diet does not directly improve tissue perfusion in this context.
Question 2 of 5
The nurse is discussing concerns the parent has with his 3-year-old. The parent identifies limitations in the child's activities. Select all that should be of concern to the nurse.
Correct Answer: A,B,D
Rationale: By age 3, children should manipulate simple toys, follow simple instructions, and name some colors or numbers. These limitations (A, B,
D) suggest developmental delays requiring further evaluation. Saying first and last name (
C) is less critical at this age.
Question 3 of 5
The nurse has completed giving medication instructions to a client receiving benazepril to treat hypertension. Which statement made by the client indicates to the nurse that the client needs further teaching?
Correct Answer: D
Rationale: Benazepril is an angiotensin-converting enzyme (ACE) inhibitor used to treat hypertension. Client education includes changing positions slowly to avoid orthostatic hypotension, monitoring blood pressure regularly, and using salt moderately as part of a heart-healthy diet. However, reporting signs and symptoms of infection is not directly related to benazepril use, as infections are not a common side effect. The client may need further teaching to clarify the specific side effects to monitor, such as cough, swelling, or signs of hyperkalemia.
Question 4 of 5
The nurse has conducted a class for pregnant clients diagnosed with diabetes mellitus about the signs/symptoms of potential complications. The nurse determines that the teaching was effective if a client makes which statement?
Correct Answer: C
Rationale: A diabetic pregnant client has a higher incidence of developing gestational hypertension than the nondiabetic pregnant client does. Ultrasounds are done frequently during a diabetic pregnancy to check for congenital anomalies and to determine appropriate growth patterns. Hypoglycemia is a problem during pregnancy in the client diagnosed with diabetes mellitus and needs to be assessed throughout the pregnancy. Insulin needs will increase during the last trimester because of increased hormone levels that destroy circulating insulin.
Question 5 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.