NCLEX-PN
Health Promotion and Maintenance NCLEX PN Questions Questions
Extract:
Question 1 of 5
A nurse assisting with data collection of a client gathers both subjective and objective data. Which finding would the nurse document as subjective data?
Correct Answer: C
Rationale: Subjective data are information provided by the client about their symptoms, feelings, or experiences. In this case, the client reporting having a rash is subjective data because it is based on what the client says.
Choices A, B, and D involve observations or measurements made by the nurse (anxious appearance, blood pressure, reflexes), which fall under objective data. Objective data are observable and measurable data obtained through physical examination, vital signs assessment, and laboratory tests.
Question 2 of 5
A client has just returned from surgery where a femoral-popliteal bypass was performed. The nurse has assessed the client and is unable to feel a pulse at either the dorsalis pedis or the posterior tibial sites of the left foot. The foot feels warm, and the color is pink. What action should the nurse perform next to prevent ischemia?
Correct Answer: B
Rationale: The nurse should immediately obtain a Doppler device and recheck the pulses. The dorsalis pedis and posterior tibial pulses can be difficult to assess and might need to be verified with a Doppler device. Since the client just had surgery with a risk of arterial insufficiency, close monitoring is crucial. If pulses are not palpable, it indicates an emergent situation requiring immediate physician notification. Waiting 30 minutes before reassessment could lead to foot ischemia. While documenting findings is essential, it should follow pulse confirmation or necessary interventions to ensure the client's foot viability.
Question 3 of 5
An LPN is taking care of an elderly client who experiences the effects of Sundowner's Syndrome almost every evening. Which of these interventions implemented by the nurse would be the most helpful?
Correct Answer: A
Rationale: A nightlight will help reorient the client to his or her surroundings in the evening and nighttime hours. It is best not to challenge the reality of a client experiencing Sundowner's Syndrome, and sedatives may make the effects of the syndrome worse. Every effort should be made to keep the client's room calm, quiet, and peaceful, so noise should be kept to a minimum. Reminding the client that what they are experiencing is not real may cause distress and confusion, while turning on the TV or radio may add unnecessary stimulation instead of promoting a soothing environment.
Question 4 of 5
A nurse working in a pediatric clinic and observes the following situations. Which of the following may indicate a delayed child to the nurse?
Correct Answer: A
Rationale: At 12 months a child should at least be 'cruising' (holding on to objects to walk).
Question 5 of 5
The client has an order for a 1,000 mL bag of fluids to be infused over 8 hours. What is the correct rate?
Correct Answer: C
Rationale:
To determine the correct infusion rate, divide the total volume of fluids (1,000 mL) by the total infusion time (8 hours), resulting in a rate of 125 mL/hr. This calculation ensures the appropriate administration of fluids over the specified time period.
Choice A (100 mL/hr) is incorrect as it does not match the calculated rate based on the given information.
Choice B (125 mL/min) is inaccurate because the question specifies the rate in hours, not minutes.
Choice D (80 mL/min) is incorrect as it provides the rate in minutes rather than hours, which is the required unit for this scenario.