NCLEX-RN
Health Promotion and Maintenance NCLEX RN Questions Questions
Extract:
Question 1 of 5
A client with a hiatal hernia asks the nurse about fluids that are safe to drink and that will not irritate the gastric mucosa. What fluid should the nurse tell the client to drink?
Correct Answer: A
Rationale: Substances that are irritating to the client with hiatal hernia include tomato products and citrus fruits, which should be avoided. Because caffeine stimulates gastric acid secretion, beverages that contain caffeine, such as coffee, tea, cola, and cocoa, are also eliminated from the diet.
Question 2 of 5
The nurse has implemented a plan of care for a client diagnosed with a cervical 5 (C5) spinal cord injury to promote health maintenance. Which client outcome indicates the effectiveness of the plan?
Correct Answer: A
Rationale: A C5 spinal cord injury results in quadriplegia with no sensation below the clavicle, including most of the arms and hands. The client maintains the partial movement of the shoulders and elbows. Maintaining intact skin is an outcome for spinal cord injury clients. The remaining options are inappropriate for this client.
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 is teaching a smoking cessation program. He will state that which of the following benefits of quitting appear within one year?
Correct Answer: B
Rationale: Within 24 hours of quitting smoking, carbon monoxide levels drop to normal. Other benefits (A, C,
D) take longer (5-15 years for heart disease, 10 years for lung cancer, 5-10 years for stroke risk). Thus, B is the correct benefit within one year.
Question 5 of 5
Percussion is a physical assessment technique that is used to identify which findings?
Correct Answer: A,B,C,F
Rationale: Percussion involves tapping the body with the fingertips to evaluate the size, borders, and consistency of body organs and assess for fluid in body cavities. Through percussion, the location, size, and density of an underlying structure can be determined. Through palpation, assessment is done via the sense of touch. Measurements of specific physical signs, including resistance, resilience, roughness, texture, and mobility, can be made through palpation.