NCLEX-PN
Health Promotion and Maintenance NCLEX PN Questions Questions
Extract:
Question 1 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.
Question 2 of 5
The nurse is caring for a female client who has recently been diagnosed with cancer and will soon begin chemotherapy. Which of these statements would require additional follow-up and education?
Correct Answer: C
Rationale: This client is at risk for altered body image due to chemotherapy-induced hair loss. A wig can assist in coping with this change. It is advisable for the client to shop for a wig before hair loss occurs to better match color and style. Waiting until all hair falls out may lead to stress and limited options in finding a suitable wig.
Choices A, B, and D are accurate. Understanding the timing of susceptibility to infection, maintaining oral health before chemotherapy, and staying hydrated are important aspects of care during chemotherapy.
Therefore, the statement 'I should wait until all my hair falls out to purchase a wig' requires additional follow-up and education.
Question 3 of 5
During a voice test, how should the nurse provide words for the client to repeat?
Correct Answer: B
Rationale: During a voice test, the nurse should whisper words from the client's side at a distance of 1 to 2 feet from the ear being tested. This distance helps prevent transmission around the head and ensures accurate testing of one ear at a time. By standing close to the client and whispering, the nurse prevents lip-reading and compensatory actions by the client. The client with normal hearing should be able to repeat each word correctly.
Choices A, C, and D are incorrect.
Choice A is wrong as the voice should be whispered, not spoken in a soft tone.
Choice C is inaccurate because a distance of 10 feet is too far for precise testing.
Choice D is incorrect as whispering from a distance of 20 feet would not effectively test the client's hearing.
Question 4 of 5
An adult client tells the clinic nurse that he is susceptible to middle ear infections. About which risk factor related to infection of the ears does the nurse question this client?
Correct Answer: D
Rationale: The correct answer is 'Exposure to cigarette smoke.' Otitis media (middle ear infection) is associated with various factors like colds, allergies, sore throats, and blockage of the eustachian tubes. Risk factors include exposure to cigarette smoke, youth (as otitis media is usually a childhood disease), congenital abnormalities, immune deficiencies, family history of otitis media, recent upper respiratory infections, and allergies.
Choices A, B, and C (Loud music, Use of power tools, and Occupational noise) are more likely to cause hearing loss rather than being direct risk factors for middle ear infections.
Question 5 of 5
A nurse is preparing to screen a client's vision with the use of a Snellen chart. The nurse uses which technique?
Correct Answer: A
Rationale:
To test visual acuity with the use of a Snellen chart, the nurse places the chart in a well-lit spot at the client's eye level, with the client positioned exactly 20 feet from the chart. The client shields one eye at a time with an opaque card during the test. After testing each eye separately, both eyes are assessed together. The client is asked to read the smallest line of letters visible and encouraged to read the next smallest line as well.
Therefore, option A is correct as it describes the correct technique of testing one eye at a time before assessing both eyes together. Option B is incorrect as it assesses both eyes together first, which is not the standard procedure. Options C and D are incorrect as they suggest standing 40 feet from the chart, which contradicts the standard distance of 20 feet for a Snellen chart test.