NCLEX-PN
Health Promotion and Maintenance NCLEX PN Questions Questions
Extract:
Question 1 of 5
How should a nurse listen to the breath sounds of a client?
Correct Answer: D
Rationale:
To best listen to breath sounds, the nurse should have the client sit, leaning slightly forward, with arms resting comfortably across the lap. The client should be instructed to breathe through the mouth a little deeper than usual, but to stop if feeling dizzy. The nurse should hold the flat diaphragm end piece of the stethoscope firmly against the client's chest wall. It is crucial to listen for at least one full respiration in each location on the chest to assess breath sounds accurately. Side-to-side comparison is essential in breath sound assessment.
Therefore, options A, B, and C are incorrect as they do not align with the correct procedure for listening to breath sounds.
Question 2 of 5
A nurse is trying to motivate a client toward more effective management of a therapeutic regimen. Which of the following actions by the nurse is most likely to be effective in increasing the client's motivation?
Correct Answer: C
Rationale: For maximum effectiveness, teach the client about the disorder at the client's level of understanding.
Question 3 of 5
The LPN has been asked to help a client taking Risperdal with activities of daily living in the morning. Which of these tasks is most likely to be potentially impacted by this medication?
Correct Answer: C
Rationale: The correct answer is 'getting out of bed to use the bathroom.' Risperdal can cause orthostatic hypotension, leading to a drop in blood pressure when changing positions from lying down to standing up. This effect increases the risk of falls, emphasizing the need to assist the client with this task to prevent potential harm.
Choices A, B, and D are less likely to be directly impacted by the medication, unlike the significant risk of orthostatic hypotension associated with changing positions.
Question 4 of 5
The LPN needs to determine the client's respiratory rate. What is the best technique to do this?
Correct Answer: D
Rationale: The best technique to determine a client's respiratory rate is to count respirations while pretending to check the client's pulse. You should not inform the client that you are counting their respirations, as this might lead to a change in their breathing pattern. Pretending to check the pulse allows you to be close to the client without revealing that you are assessing their respiratory rate. Asking the client to sit still may not be as effective, as it may cause them to concentrate on their breathing. Watching from across the room may not provide an accurate assessment of respirations, as they might be difficult to observe.
Question 5 of 5
The client has an order for a 1,000 mL bag of fluids to be infused over 8 hours. What is the correct rate?
Correct Answer: C
Rationale:
To determine the correct infusion rate, divide the total volume of fluids (1,000 mL) by the total infusion time (8 hours), resulting in a rate of 125 mL/hr. This calculation ensures the appropriate administration of fluids over the specified time period.
Choice A (100 mL/hr) is incorrect as it does not match the calculated rate based on the given information.
Choice B (125 mL/min) is inaccurate because the question specifies the rate in hours, not minutes.
Choice D (80 mL/min) is incorrect as it provides the rate in minutes rather than hours, which is the required unit for this scenario.