NCLEX-PN
Health Promotion and Maintenance NCLEX PN Questions Questions
Extract:
Question 1 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 2 of 5
Which of the following is not a nursing responsibility when preparing the client for central line insertion?
Correct Answer: A
Rationale: When preparing a client for central line insertion, nursing responsibilities include explaining the procedure to the client, ensuring necessary consents are signed according to the facility policy, and maintaining sterile technique when preparing the equipment and supplies. Advancing the guidewire is typically performed by the practitioner inserting the central line, not the nurse. It requires specialized training and expertise beyond the scope of nursing practice.
Therefore, the correct answer is advancing the guidewire. Option A is the correct answer because it delineates an activity that is not within the usual scope of nursing practice during central line insertion preparation. Options B, C, and D are incorrect as they reflect essential nursing responsibilities in this context.
Question 3 of 5
While assisting with data collection, the client informs the nurse that he is having difficulty swallowing medications and food. The nurse gathers additional subjective data and documents that the client is experiencing which disorder?
Correct Answer: D
Rationale: The correct answer is 'Dysphagia.' Dysphagia is the term used to indicate difficulty swallowing, which can occur in disorders of the throat or esophagus. Anorexia refers to a loss of appetite, not difficulty swallowing. Eructation is the medical term for belching, not difficulty swallowing. Pyrosis is heartburn, a burning sensation in the esophagus and stomach caused by the reflux of gastric acid, not difficulty swallowing.
Question 4 of 5
When assessing the carotid artery of a client with cardiovascular disease, what action should a nurse perform?
Correct Answer: C
Rationale: When assessing the carotid artery of a client with cardiovascular disease, the nurse should listen to the carotid artery using the bell of the stethoscope to assess for bruits. This is crucial in detecting abnormal sounds that may indicate underlying pathology. Palpating the carotid artery in the upper third of the neck can trigger a vagal response, leading to a decrease in heart rate, which is undesirable. Palpating both arteries simultaneously can disrupt blood flow to the brain. Instructing the client to take slow, deep breaths is unnecessary and not a standard practice during carotid artery assessment.
Question 5 of 5
During a throat assessment, a healthcare provider asks a client to stick out their tongue and notices it protrudes in the midline. Which cranial nerve is being tested?
Correct Answer: D
Rationale: The correct answer is cranial nerve XII (hypoglossal nerve). When testing cranial nerve XII, the healthcare provider inspects the symmetry and movement of the tongue. The tongue should protrude in the midline when the client sticks it out. Cranial nerve IX (glossopharyngeal nerve) and X (vagus nerve) are tested by depressing the tongue with a blade to observe pharyngeal movement and gag reflex. Cranial nerve V (trigeminal nerve) is responsible for testing the muscles of mastication, not tongue protrusion.