NCLEX-PN
Health Promotion and Maintenance NCLEX Questions Questions
Extract:
Question 1 of 5
A nurse in the newborn nursery, assisting with data collection for a newborn, prepares to measure the chest circumference. The nurse places the tape measure around the infant at which location?
Correct Answer: B
Rationale: The chest circumference of the infant is measured at the level of the nipples. It is usually 2 to 3 cm smaller than the head circumference. The average chest circumference is 30.5 to 33 cm (12-13 inches). When there is molding of the head, the head and chest measurements may be equal at birth. Placing the tape measure at the level of the nipples ensures accuracy and consistency in newborn assessment. Options A, C, and D are incorrect as the chest circumference is specifically measured at the level of the nipples to obtain precise measurements.
Question 2 of 5
A nurse demonstrates the procedure for bathing a newborn to a new mother. The next day, the nurse watches as the mother bathes the infant. The nurse determines that the mother is performing the procedure correctly if the mother performs which action?
Correct Answer: B
Rationale: When bathing a newborn, it is crucial to follow a specific sequence for thorough cleaning and safety. The correct sequence includes starting with the eyes and face, then moving to the external ear, areas behind the ears, neck, hands, arms, legs, and finally the diaper area. Keeping the infant warm is essential, so only the body part being washed should be uncovered. Using a cotton-tipped swab to clean inside the infant's nose is not recommended due to the risk of injury if the infant moves suddenly. Washing the diaper area first is incorrect as it should be done towards the end of the bath to prevent contamination. Washing the infant's chest first is also incorrect as it deviates from the recommended bathing sequence for a newborn.
Question 3 of 5
A nurse preparing to examine a client’s eyes plans to perform a confrontation test. The nurse tells the client that this test measures which aspect of vision?
Correct Answer: D
Rationale: The correct answer is D: Peripheral vision. The confrontation test is a gross measure of peripheral vision. It compares the client’s peripheral vision with the nurse’s, assuming that the nurse’s vision is normal. During the test, the nurse positions themselves at eye level with the client, about 2 feet away, and directs the client to cover one eye with an opaque card. The nurse covers the eye opposite the client’s covered one and slowly moves a target (like a pencil) from the periphery in several directions. The client is asked to indicate when they see the target, which should coincide with when the nurse sees it. Near vision is tested using a handheld vision screener with various sizes of print, color vision with the Ishihara test, and distant vision with a Snellen chart.
Therefore, choices A, B, and C are incorrect as they do not measure peripheral vision, which is the focus of the confrontation test.
Question 4 of 5
Which of the following vaccines is not part of the regular schedule of immunizations for children?
Correct Answer: D
Rationale: The correct answer is hepatitis A. DTaP, MMR, and Hib are all part of the regular schedule of immunizations for children to protect them against diseases like diphtheria, tetanus, pertussis, measles, mumps, rubella, and Haemophilus influenzae type b. Hepatitis A vaccine is not included in the routine childhood immunization schedule but may be recommended in certain situations or regions where the disease is more prevalent. Hepatitis A is generally considered an optional vaccine for children but can be administered based on specific risk factors or regional guidelines.
Question 5 of 5
The intravenous route is potentially the most dangerous route of drug administration because:
Correct Answer: C
Rationale: The bioavailability of the injected medication is 100% and might lead to toxicity. An IV infiltration can cause serious problems with tissue necrosis, but this is not life threatening. Expensive and time consuming do not equate with dangerous. Not all clients experience more side effects with IV administration.