NCLEX-PN
Health Promotion and Maintenance NCLEX PN Questions Questions
Extract:
Question 1 of 5
During data collection of a client with suspected carpal tunnel syndrome, a nurse plans to perform the Phalen test. The nurse should ask the client to perform which activity?
Correct Answer: C
Rationale: In the Phalen test, the nurse asks the client to hold the hands back to back while flexing the wrists 90 degrees. This position puts pressure on the median nerve, eliciting symptoms in carpal tunnel syndrome. Dorsiflexing or plantarflexing the foot and hyperextending the fingers are not associated with testing for carpal tunnel syndrome. Acute flexion of the wrist for 60 seconds produces no symptoms in the normal hand.
Question 2 of 5
A nurse sees documentation in the client's record indicating that the health care provider has noted the presence of adventitious breath sounds. The nurse knows that these types of sounds have which aspect?
Correct Answer: D
Rationale: Adventitious breath sounds are abnormal sounds that are not normally heard in the lungs. These sounds are added sounds superimposed on the breath sounds. They are caused by air colliding with secretions in the tracheobronchial passageways or when previously deflated airways pop open. Hollow sounds heard over the trachea and larynx are normal bronchial (tracheal) breath sounds, not adventitious. Rustling sounds heard over the peripheral lung fields are normal vesicular breath sounds, not adventitious.
Therefore, the correct answer is that adventitious breath sounds are abnormal sounds that should not be heard in the lungs.
Question 3 of 5
A client with peripheral artery disease tells the nurse that pain develops in his left calf when he is walking and subsides with rest. The nurse documents that the client is most likely experiencing which disorder?
Correct Answer: B
Rationale: Leg pain characteristic of peripheral artery disease is known as intermittent claudication. The client can walk only a certain distance before cramping, burning, muscle discomfort, or pain forces them to stop, with the pain subsiding after rest. The pain is reproducible, and as the disease progresses, the client can walk shorter distances before the pain recurs. Ultimately, pain may even occur at rest. Venous insufficiency (
Choice
A) involves impaired blood flow in the veins, leading to swelling and skin changes but not typically pain associated with exercise. Sore muscles from overexertion (
Choice
C) and muscle cramps related to musculoskeletal problems (
Choice
D) do not present with the characteristic pattern of pain associated with peripheral artery disease.
Question 4 of 5
Which of the following actions should the LPN perform for a client with an active digoxin IV order? Select all that apply.
Correct Answer: D
Rationale: The correct actions for the LPN to perform for a client with an active digoxin IV order are to monitor ECG rhythm throughout administration and monitor the client's pulse for 1 minute prior to administration. These actions are crucial as digoxin affects the heart's electrical activity, and it should not be administered if the client's pulse is less than 60 bpm. Monitoring respirations and blood pressure are not directly associated with digoxin administration. Administering IV medications is typically outside the LPN's scope of practice.
Question 5 of 5
During the examination of a client's throat, a nurse touches the posterior wall with a tongue blade and elicits the gag reflex. The nurse documents normal function of which cranial nerves?
Correct Answer: D
Rationale: The correct answer is cranial nerves IX (glossopharyngeal nerve) and X (vagus nerve). When the nurse touches the posterior pharyngeal wall with a tongue blade and elicits the gag reflex, it indicates normal function of these nerves. Cranial nerves V (trigeminal nerve) and VI (abducens nerve) are not directly responsible for the gag reflex. Cranial nerves XII (hypoglossal nerve) and VIII (vestibulocochlear nerve) are not directly involved in eliciting the gag reflex. Testing cranial nerve I involves smell function, and cranial nerve II is related to eye examinations, making them irrelevant in this scenario.