NCLEX-RN
Health Promotion and Maintenance NCLEX RN Questions Questions
Extract:
Question 1 of 5
A healthcare professional is preparing to insert an indwelling catheter in a female client. Which of the following positions of the client is most appropriate for this procedure?
Correct Answer: C
Rationale: When preparing to insert an indwelling catheter for a female client, the most appropriate position is the dorsal recumbent position. In this position, the client lies on their back with knees bent. This position allows for easy access to the urethral area for catheter insertion. The lithotomy position, with legs elevated and spread apart, is more invasive and typically used for gynecological exams. The prone position, lying face down, is not suitable for catheter insertion. High Fowler's position, sitting upright at a 90-degree angle, is not ideal for catheter insertion as it does not provide proper access to the perineal area.
Question 2 of 5
Mr. N is a client who entered the hospital with a diagnosis of diabetic ketoacidosis. The nurse enters his room to check his vital signs and finds him breathing at a rate of 32 times per minute; his respirations are deep and regular. Which type of respiratory pattern is Mr. N most likely exhibiting?
Correct Answer: A
Rationale: Mr. N is exhibiting Kussmaul respirations, characterized by rapid, deep, and regular breathing. This type of respiratory pattern is commonly seen in metabolic acidosis, such as in diabetic ketoacidosis. Kussmaul respirations are a form of hyperventilation, leading to the elimination of carbon dioxide from the body.
Choice B, Cheyne-Stokes respirations, is characterized by alternating periods of deep, rapid breathing followed by periods of apnea and is not typically associated with diabetic ketoacidosis.
Choice C, Biot's respirations, involve irregular breathing patterns with periods of apnea and are not reflective of the described breathing pattern. Cluster breathing, as mentioned in
Choice D, is not a recognized term in respiratory patterns and does not describe the breathing pattern observed in Mr. N.
Question 3 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 4 of 5
What factors should the nurse consider for teaching a child about his or her disease and related health care measures?
Correct Answer: C,D,F
Rationale: For children, the teaching-learning process may be fundamentally different from that used for adults, and the nurse needs to adjust the complexity and volume of information based on the child's age and cognitive level. The factors that need to be addressed when teaching children include the following: Trust is essential to a therapeutic relationship; in general, the younger the child, the shorter the attention span; assessing the child's knowledge is important because children are exposed to various levels of information about health care; children form misconceptions easily, and a child's imagination may create greater fear than the truth; a child may regress developmentally in a situation of illness; and a child may better manage uncomfortable information through role-playing.
Question 5 of 5
Which of the following situations might warrant a laboratory magnesium level?
Correct Answer: C
Rationale: Ulcerative colitis can lead to symptoms such as abdominal pain, fever, diarrhea, and weight loss. This condition may impact the absorption of certain nutrients, including magnesium.
Therefore, patients with chronic gastrointestinal conditions like ulcerative colitis should be screened for electrolyte imbalances related to impaired digestion. Hyperthyroidism, arthritis, and depression do not typically directly affect magnesium levels in the same way as gastrointestinal conditions like ulcerative colitis.