NCLEX-RN
Health Promotion and Maintenance NCLEX RN Questions Questions
Extract:
Question 1 of 5
The nurse is discussing concerns the parent has with his 3-year-old. The parent identifies limitations in the child's activities. Select all that should be of concern to the nurse.
Correct Answer: A,B,D
Rationale: By age 3, children should manipulate simple toys, follow simple instructions, and name some colors or numbers. These limitations (A, B,
D) suggest developmental delays requiring further evaluation. Saying first and last name (
C) is less critical at this age.
Question 2 of 5
Mr. Y had surgery two days ago and is recovering on the surgical unit of the hospital. Just before lunch, he develops chest pain and difficulties with breathing. His respiratory rate is 32/minute, his temperature is 100.8°F, and he has rales on auscultation. Which of the following nursing interventions is most appropriate in this situation?
Correct Answer: C
Rationale: Chest pain, dyspnea, tachypnea, mild fever, and rales or crackles on auscultation in a client who had surgery 2 days ago may be indicative of a pulmonary embolism. The nurse should administer oxygen to address his breathing and assist him to a comfortable position to facilitate better oxygenation before contacting the physician. Placing the client in the Trendelenburg position is not recommended in this situation as it may worsen a potential pulmonary embolism by increasing venous return. Contacting the physician for antibiotics is not the priority as the immediate concern is addressing the breathing difficulty. Decreasing the IV rate is not indicated in this situation where the client is experiencing respiratory distress and needs oxygen therapy.
Question 3 of 5
A client with a hiatal hernia asks the nurse about fluids that are safe to drink and that will not irritate the gastric mucosa. What fluid should the nurse tell the client to drink?
Correct Answer: A
Rationale: Substances that are irritating to the client with hiatal hernia include tomato products and citrus fruits, which should be avoided. Because caffeine stimulates gastric acid secretion, beverages that contain caffeine, such as coffee, tea, cola, and cocoa, are also eliminated from the diet.
Question 4 of 5
The nurse has given instructions to the client diagnosed with chronic kidney disease about reducing pruritus from uremia. The nurse determines that the client needs further teaching if the client states the intention to use which item for skin care?
Correct Answer: D
Rationale: Alcohol cleansing pads increase skin dryness and pruritus in chronic kidney disease clients with uremia. Mild soap, bath oils, and lanolin-based lotions help reduce dryness and irritation without exacerbating symptoms.
Question 5 of 5
The nurse monitors a client for brachial plexus compromise after shoulder arthroplasty and is checking the status of the ulnar nerve. Which technique should the nurse use to assess the status of this nerve?
Correct Answer: B
Rationale: So that the nurse may assess the ulnar nerve status, the client is asked to spread all of the fingers wide and resist pressure. Weakness against pressure may indicate compromise of the ulnar nerve. Raising the forearm above the head assesses the flexion of the biceps and determines the status of the cutaneous nerve. Moving the thumb toward the palm and back describes the assessment of the status of the radial nerve. Having the client grasp the nurse's hand and assessing the strength of the first 2 fingers describes the assessment of the status of the medial nerve.