NCLEX-PN
Health Promotion and Maintenance NCLEX Questions Questions
Extract:
Question 1 of 5
A woman who delivered a healthy newborn 6 hours earlier complains of discomfort at the episiotomy site. Which action by the nurse is the most appropriate?
Correct Answer: C
Rationale: Applying an ice pack to the perineum is the most appropriate action in this scenario. Ice causes vasoconstriction, providing relief by numbing the area and preventing edema. It is typically used within the first 12 to 24 hours after birth. Assisting the woman in taking a warm sitz bath is more suitable after 24 hours as warm water can be soothing. Administering an IV opioid analgesic is excessive; an anesthetic spray is more appropriate for surface discomfort. Contacting the registered nurse is unnecessary as applying an ice pack is within the nurse's scope and can effectively address the discomfort without escalation.
Question 2 of 5
The client provides information to a pregnant client who is experiencing nausea and vomiting about measures to relieve the discomfort. Which statement by the mother indicates the need for further information?
Correct Answer: B
Rationale:
To alleviate nausea and vomiting, the client should avoid drinking liquids with meals. The client should keep dry crackers at her bedside, avoid fried foods, and eat smaller meals. Additionally, the client should eat dry crackers every 2 hours to prevent an empty stomach and avoid spicy foods and foods with strong odors, such as onion and cabbage. The incorrect choices are:
A) Eating five or six small meals a day instead of three full meals is a correct recommendation.
C) Keeping dry crackers at her bedside and eating them before getting out of bed in the morning is a helpful suggestion.
D) Avoiding fried or greasy foods is a valid advice to alleviate nausea and vomiting.
Question 3 of 5
A patient has just been prescribed Minipress to control hypertension. The nurse should instruct the patient to be observant of the following:
Correct Answer: A
Rationale: Hypotension may be result of over correction of a hypertensive condition.
Question 4 of 5
When preparing to listen to a client's breath sounds, what technique should a nurse use?
Correct Answer: D
Rationale: When preparing to listen to a client's breath sounds, a nurse should ask the client to sit and lean forward slightly, with the arms resting comfortably across the lap. The client should be instructed to breathe through the mouth a little more deeply than usual but to stop if feeling dizzy. The nurse should use the flat diaphragm end-piece of the stethoscope, holding it firmly on the chest wall. By using the diaphragm, the nurse can listen for at least one full respiration in each location, moving from side to side to compare sounds. This technique ensures a systematic and thorough assessment of lung sounds.
Choice A is correct as it includes the proper positioning of the client and specifies the use of the diaphragm of the stethoscope.
Choice B is incorrect as both lungs should be auscultated systematically, starting from the top and moving down.
Choice C is incorrect as deep breaths, not shallow ones, are recommended for an accurate assessment of breath sounds.
Question 5 of 5
A nurse preparing to assist with data collection of the abdomen asks the client to void and then assists the client into a supine position. Which primary finding does the nurse expect to note on percussing all four quadrants of the abdominal cavity?
Correct Answer: B
Rationale: The nurse expects to primarily note tympany when percussing the abdomen. Tympany should predominate because air in the intestines rises to the surface when the client is in a supine position. Dullness is usually heard over a distended bladder, adipose tissue, fluid, or a mass. Borborygmus, which refers to hyperperistalsis, is typically heard on auscultation, not percussion. Hyperresonance is present with gaseous distention, not the typical finding when percussing all four quadrants of the abdomen.