NCLEX-RN
Health Promotion and Maintenance NCLEX RN Questions Questions
Extract:
Question 1 of 5
A nurse is caring for an 83-year-old man who has had swallowing difficulties. All of the following interventions are appropriate for this client EXCEPT:
Correct Answer: A
Rationale: When caring for a client with swallowing difficulties, it is crucial to prevent aspiration of food into the lungs. Appropriate interventions include auscultating lung sounds every shift and after feedings to assess for any changes in breathing patterns, maintaining suction equipment at the client's bedside in case of difficulties, and providing instruction on swallowing exercises. Keeping the client in an upright position at all times is not necessary and may not always be feasible or comfortable for the client. This rigid requirement is not part of the standard care protocol for managing swallowing difficulties.
Question 2 of 5
A client has a right-sided chest tube with 50 cc of serosanguinous fluid in the collection chamber and air bubbles are collecting in the water seal chamber. What is the most appropriate action for the nurse to take at this time?
Correct Answer: C
Rationale: The water seal of a chest tube acts as a one-way valve. Air bubbles in the water seal indicate a leak between the client and the chamber. The nurse should briefly clamp the tube near the client's chest to locate the source of the leak. Once identified, the nurse should unclamp the tubing and notify the physician immediately.
Choice A is incorrect because air bubbles in the water seal chamber are not a normal finding and indicate a leak.
Choice B is incorrect as stripping the tubing could aggravate the issue and is not the initial appropriate action.
Choice D is incorrect as it does not address the immediate need to locate and address the leak.
Question 3 of 5
The nurse has completed giving medication instructions to a client receiving benazepril to treat hypertension. Which statement made by the client indicates to the nurse that the client needs further teaching?
Correct Answer: D
Rationale: Benazepril is an angiotensin-converting enzyme (ACE) inhibitor used to treat hypertension. Client education includes changing positions slowly to avoid orthostatic hypotension, monitoring blood pressure regularly, and using salt moderately as part of a heart-healthy diet. However, reporting signs and symptoms of infection is not directly related to benazepril use, as infections are not a common side effect. The client may need further teaching to clarify the specific side effects to monitor, such as cough, swelling, or signs of hyperkalemia.
Question 4 of 5
The nurse is teaching the client about smoking cessation. Which client statement indicates a need for further teaching by the nurse?
Correct Answer: B
Rationale: E-cigarettes are not FDA-approved for smoking cessation and may still pose health risks. Other statements are accurate.
Question 5 of 5
The nurse is teaching a client with atrial fibrillation about the need to begin long-term anticoagulant therapy. Which explanation should the nurse use to best describe the reasoning for this therapy?
Correct Answer: D
Rationale: In atrial fibrillation, the quivering atria cause sluggish blood flow, leading to clot formation along the heart wall, which can dislodge and cause pulmonary or cerebral emboli. Options A, B, and C inaccurately describe the mechanism requiring anticoagulation.