NCLEX-PN
Health Promotion and Maintenance NCLEX Questions Questions
Extract:
Question 1 of 5
A nurse is caring for a pregnant client in the labor unit who suddenly experiences spontaneous rupture of the membranes. On inspecting the amniotic fluid, the nurse notes that it is clear, with creamy white flecks. What is the most appropriate action for the nurse to take based on this finding?
Correct Answer: D
Rationale: Amniotic fluid should be clear and may include bits of vernix, the creamy white fetal skin lubricant.
Therefore, the nurse would most appropriately document the findings. Checking the client's temperature, reporting the findings to the nurse-midwife, and obtaining a sample of the amniotic fluid for laboratory analysis are not necessary in this situation. Cloudy, yellow, or foul-smelling amniotic fluid suggests infection, while green fluid indicates that the fetus passed meconium before birth. If abnormalities are noted, the nurse should notify the nurse-midwife.
Question 2 of 5
While performing a physical assessment on a 6-month-old infant, the nurse observes head lag. Which of the following nursing actions should the nurse perform first?
Correct Answer: B
Rationale: Head lag should be completely resolved by 4 months of age. Continuing head lag at 6 months of age indicates the need for further developmental or neurological evaluation. Laying the infant on his stomach promotes muscle development of the neck and shoulder muscles, but because of the age of this child, a referral should be the first action. The findings are abnormal for a 6-month-old infant. Significant head lag can be seen in infants with Down syndrome and hypoxia, as well as neurological and other metabolic disorders. While some of these disorders might include developmental delays, stating this to the parents without a proper evaluation can cause unnecessary distress. The priority is to identify the cause of the head lag through a medical evaluation before discussing potential outcomes with the parents.
Question 3 of 5
A nurse assisting with data collection plans to assess tactile (vocal) fremitus. The nurse performs this by using which technique?
Correct Answer: D
Rationale:
To assess tactile (vocal) fremitus, the nurse palpates the thorax and compares vibrations from side to side as the client repeats the word 'ninety-nine.' This technique helps in evaluating the intensity and symmetry of vibrations felt. Palpating for symmetric chest expansion involves assessing the expansion of the chest during breathing by placing hands on the anterolateral wall. Auscultating the breath sounds over the trachea and larynx is done to assess bronchial breath sounds, while auscultating over the peripheral lung fields is used to assess vesicular breath sounds.
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
A client is taught about healthy dietary measures and the MyPlate food plan. How many of his grains should be whole grains according to the MyPlate food plan?
Correct Answer: C
Rationale: The correct answer is 'One-half.' According to the MyPlate food plan, at least half of the grains consumed daily should be whole grains. This ensures a well-balanced and healthy diet.
Choices A, B, and D are incorrect because they do not align with the dietary recommendation provided by the MyPlate food plan. One-quarter, one-third, and two-thirds do not represent the appropriate proportion of whole grains as advised by the plan, which emphasizes the importance of including a significant portion of whole grains in one's diet.