NCLEX-PN
Health Promotion and Maintenance NCLEX PN Questions Questions
Extract:
Question 1 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 2 of 5
When examining the abdomen, a nurse auscultates before palpating and percussing the abdomen. The nurse performs the assessment in this manner for which reason?
Correct Answer: B
Rationale: When performing an abdominal assessment, the nurse auscultates the abdomen after inspection. Auscultation is done before palpation and percussion because these assessment techniques can increase peristalsis, which would yield a false interpretation of bowel sounds. This sequence helps prevent false interpretations of bowel sounds due to increased peristalsis caused by palpation and percussion. Options A, C, and D provide incorrect reasons for auscultating the abdomen before palpating and percussing it.
Question 3 of 5
A nurse is reviewing the findings of a physical examination documented in a client's record. Which piece of information does the nurse recognize as objective data?
Correct Answer: D
Rationale: Objective data in a physical examination are findings that the healthcare provider observes or measures directly. In this case, a 1 × 2-inch scar present on the lower right portion of the abdomen is a physical observation. Subjective data are based on what the client reports, such as allergies (
Choice
A), the date of the last menstrual period (
Choice
B), and self-reported medication use for headaches (
Choice
C). While these pieces of information are important for assessing the client's health, they are considered subjective data because they rely on the client's self-report rather than direct observation by the healthcare provider.
Question 4 of 5
The client is being discharged with a prescription for an inhaled glucocorticoid for asthma. Which of the following statements indicates additional education is needed prior to discharge?
Correct Answer: B
Rationale: The correct answer is, 'I will wait five minutes after taking this medication and then gargle water.' After using an inhaled glucocorticoid, it is essential to wait for 5 minutes and then gargle water to remove any residue from the mouth, which can reduce the risk of developing thrush, a fungal infection.
Choice A is correct as holding the breath for 10 seconds after each puff helps the medication reach deep into the lungs.
Choice C is also correct as waiting at least one minute between puffs ensures proper delivery of the medication.
Choice D is incorrect because it is important to take the medication daily as prescribed to control asthma symptoms, even if the person is not experiencing any at that moment.
Question 5 of 5
A 64 year-old male who has been diagnosed with COPD and CHF exhibits an increase in total body weight of 10 lbs. over the last few days. The nurse should:
Correct Answer: B
Rationale: Checking the intake and output prior to making any decisions about patient care helps determine if the weight gain is due to fluid retention, a common issue in CHF.