NCLEX-RN
Health Promotion and Maintenance NCLEX RN Questions Questions
Extract:
Question 1 of 5
Mr. N is a client who entered the hospital with a diagnosis of diabetic ketoacidosis. The nurse enters his room to check his vital signs and finds him breathing at a rate of 32 times per minute; his respirations are deep and regular. Which type of respiratory pattern is Mr. N most likely exhibiting?
Correct Answer: A
Rationale: Mr. N is most likely exhibiting Kussmaul respirations. Kussmaul respirations are a form of hyperventilation associated with conditions like metabolic acidosis. They are characterized by rapid, regular, and deep breathing. This type of respiratory pattern helps the body compensate for metabolic acidosis by attempting to blow off excess carbon dioxide. This pattern is different from Cheyne-Stokes respirations (choice
B), which are characterized by alternating periods of deep, rapid breathing followed by apnea. Biot's respirations (choice
C) are characterized by groups of quick, shallow inspirations followed by irregular periods of apnea, and Cluster breathing (choice
D) involves clusters of breaths followed by periods of apnea, often seen in patients with brain injury or neurological conditions.
Question 2 of 5
The nurse provides home care instructions to a client diagnosed with cancer who has an implanted vascular access port. Which statement by the client indicates the need for further teaching?
Correct Answer: C
Rationale: Implanted vascular access ports do not require daily pumping to maintain patency; this is incorrect. Keeping the site clean and dry, notifying the doctor about redness, and flushing with saline (or heparin, per agency protocol) are correct care measures.
Question 3 of 5
A client in labor has an electronic fetal monitor attached to the abdomen, and the nurse notes that the baby's heart rate slows down during each contraction, returning to normal limits only after the contraction is complete. Which type of fetal heart rate change does this pattern describe?
Correct Answer: B
Rationale: Late decelerations refer to a pattern where the baby's heart rate decreases during contractions and does not return to normal until after the contraction ends. This is considered a non-reassuring sign as it indicates potential fetal distress. Late decelerations are associated with uteroplacental insufficiency, and immediate medical attention is required. Variable decelerations (
Choice
A) are abrupt, unpredictable decreases in the fetal heart rate, usually associated with cord compression. Early decelerations (
Choice
C) are usually benign and mirror the contraction pattern. Accelerations (
Choice
D) are reassuring signs of fetal well-being, characterized by an increase in the fetal heart rate.
Question 4 of 5
Which of the following is a true statement about assessing blood pressure by palpation?
Correct Answer: D
Rationale: When assessing blood pressure by palpation, it is important to note that only the systolic blood pressure can be determined accurately using this method. Diastolic blood pressure cannot be reliably assessed through palpation. The palpation technique is particularly useful in situations where traditional blood pressure measurement methods are challenging, such as in infants, small children, or individuals with low blood pressure that is difficult to hear. Hypertension, a common condition characterized by elevated blood pressure, is typically assessed using auscultation rather than palpation.
Therefore, the correct statement is that only the systolic blood pressure can be assessed through palpation.
Question 5 of 5
The nurse is teaching a 28-year-old male client about testicular cancer. Which statement by the client indicates understanding of the nurse's teaching?
Correct Answer: D
Rationale: Testicular self-examination is best post-bathing due to scrotal relaxation. Testicular cancer is common in 15-35-year-olds but highly treatable, and any lump should be reported.