NCLEX-RN
Health Promotion NCLEX RN Exam Questions Questions
Extract:
Question 1 of 5
A client who sustained a thoracic cord injury a year ago returns to the clinic for a follow-up visit, and the nurse notes a small reddened area on the coccyx. The client is not aware of the reddened area. After counseling the client to relieve pressure on the area by adhering to a turning schedule, which action by the nurse is most appropriate?
Correct Answer: C
Rationale: The client should be encouraged to be as independent as possible. The most effective means of skin self-assessment for this client is with the use of a mirror. The redness cannot be felt. Asking a family member to assess the skin daily does not promote independence. It is unnecessary and unrealistic for the client to return to the clinic daily for a skin check.
Question 2 of 5
A community health nurse is lecturing students at a nearby community college about high-risk behavior. Which of the following should the nurse include in the lecture?
Correct Answer: D
Rationale: Unintentional injuries (e.g., car accidents) are the leading cause of death in college-age students. Suicide and homicide rank lower, and cancer is not third.
Question 3 of 5
A client is diagnosed with hyperphosphatemia caused by hypoparathyroidism. To prevent worsening of the condition, the nurse should instruct the client to avoid which food selections? Select all that apply.
Correct Answer: A,B,F
Rationale: Food items and liquids that are naturally high in phosphates include fish, eggs, milk products, whole grains, vegetables, and carbonated beverages, and they should be avoided by the client with hyperphosphatemia. Coffee, grapes, and bananas are acceptable for this client to consume because their phosphate levels are not significant.
Question 4 of 5
The home-care nurse visits an older client diagnosed with Parkinson's disease who requires instillation of multiple eye drops. Which instruction for the administration of eye drops should the nurse plan to provide to this client who demonstrates signs/symptoms of this diagnosis?
Correct Answer: C
Rationale: Older adults diagnosed with Parkinson's disease will experience tremors, making it more difficult to instill eye drops. The older client is instructed to lie down on a bed or sofa to instill the eye drops to provide control and allow the drops to be administered more easily. If multiple eye drops are needed, there should be a wait time of 3 to 4 minutes between drops. It is unreasonable to expect a family member to be available consistently to instill the eye drops. Additionally, this discourages client independence. Placing the eye drops in the refrigerator should not be done unless specifically prescribed.
Question 5 of 5
A client is receiving lipids (fat emulsion) intravenously at home, and the client's spouse manages the infusion. The home care nurse makes a visit and discusses potential side and adverse effects of the therapy with the client and the spouse. After the discussion, the nurse expects the spouse to verbalize that, in case of a suspected adverse effect, which action is the priority?
Correct Answer: A
Rationale: Signs/symptoms of an adverse effect to lipids (fat emulsion) include chest and back pain, chills, vertigo, cyanosis, diaphoresis, dyspnea, fever, flushing, headache, nausea and vomiting, and thrombophlebitis of the vein. The priority action is to stop the infusion to limit the adverse response. Although contacting the nurse, taking the client's blood pressure, and contacting the local emergency response team are correct interventions, the priority is to stop the infusion.