NCLEX-PN
Health Promotion and Maintenance NCLEX PN Questions Questions
Extract:
Question 1 of 5
A nurse assisting with data collection uses the back of the hand to feel the client's skin on both arms and notes that the skin is warm. The nurse makes which determination?
Correct Answer: B
Rationale:
To assess skin temperature, the nurse would first note the temperature of their own hands.
Then, using the backs of the hands to palpate the client's skin bilaterally, warmth suggests normal circulatory status if the skin is warm and the temperature is equal bilaterally. The hands and feet may feel slightly cooler in a cool environment. Options A, C, and D are incorrect responses. A warm skin temperature does not indicate a fever, the need for additional fluids, or the need to have the blanket removed.
Question 2 of 5
A nurse is auscultating for vesicular breath sounds in a client. Of which quality would the nurse expect these normal breath sounds to be?
Correct Answer: D
Rationale: The correct answer is D: 'Rustling.' Vesicular breath sounds are described as rustling and resemble the sound of wind blowing through trees. Harsh, hollow, and tubular sounds are associated with bronchial (tracheal) breath sounds, not vesicular breath sounds. Harsh sounds are high-pitched, hollow sounds are reverberating, and tubular sounds are like blowing air into a tube.
Therefore, options A, B, and C are incorrect descriptions of vesicular breath sounds and are more characteristic of bronchial breath sounds.
Question 3 of 5
When performing an eye examination, which area can a healthcare provider best visualize using an ophthalmoscope?
Correct Answer: C
Rationale: An ophthalmoscope is a tool used to visualize the internal structures of the eye during an examination. The optic disc, located on the internal surface of the retina, can be best visualized using an ophthalmoscope. The iris, cornea, and conjunctiva are superficial structures that can be examined without the need for an ophthalmoscope.
Therefore, the correct answer is the optic disc.
Choices A, B, and D are incorrect because they are external structures that can be examined directly without the use of an ophthalmoscope.
Question 4 of 5
The LPN is taking care of a client with a documented allergy to Penicillin. After rounds, the LPN notices that the client has an order for Cefazolin. Which of the following actions would be the least appropriate?
Correct Answer: C
Rationale: The least appropriate action is for the LPN to administer all ordered medications except for the Cefazolin. The LPN should always consider the client's documented allergy to Penicillin seriously. It is crucial to discuss the order with the care team before administering Cefazolin to ensure patient safety. Administering a medication that could potentially cause harm due to a documented allergy is unsafe practice. While monitoring the client after a test dose of Cefazolin is important, it should not precede clarification with the care team regarding the allergy and the appropriateness of the medication.
Therefore, withholding the Cefazolin is the most appropriate action in this scenario.
Question 5 of 5
When caring for a patient who is hard-of-hearing, which of the following steps may be appropriate when communicating with the patient?
Correct Answer: A
Rationale: When caring for a patient who is hard-of-hearing, it is important to divide verbal communication into smaller sections and address them one at a time. This approach helps the patient follow along more easily and understand the information being conveyed. While using written information can also be beneficial, solely relying on written communication may not always be practical or feasible for effective interaction. Asking multiple questions quickly can overwhelm the patient and hinder their ability to process each question adequately. It is essential to give the patient sufficient time to comprehend and respond. Additionally, frequently communicating without assistive devices is not recommended. Using assistive devices can significantly enhance the patient's ability to hear and understand, promoting better communication and patient care.