NCLEX-RN
Health Promotion and Maintenance NCLEX RN Questions Questions
Extract:
Question 1 of 5
The nurse is providing teaching to a client newly diagnosed with hypertension. The nurse knows that the client understands the teaching when the client selects which menu option?
Correct Answer: B
Rationale: Baked chicken and fresh green beans are low-sodium, suitable for hypertension. Other options are high in sodium.
Question 2 of 5
Clonazepam has been prescribed for the client, and the nurse teaches the client about the medication. Which statement by the client indicates that further teaching is necessary?
Correct Answer: A
Rationale: Clonazepam is a benzodiazepine. Clients who experience signs/symptoms of toxicity with the administration of clonazepam exhibit slurred speech, sedation, confusion, respiratory depression, hypotension, and eventually coma. Some drowsiness may occur, but it will decrease with continued use. The medication may be taken with food to decrease gastrointestinal irritation. The medication may be taken at bedtime if drowsiness does occur. Slurred speech indicates toxicity and should be reported immediately, not expected to disappear in 8 weeks.
Question 3 of 5
A client diagnosed with heart failure and secondary hyperaldosteronism is started on spironolactone to manage this disorder. The nurse informs the client that the need for dosage adjustment may be necessary if which medication is also being taken?
Correct Answer: C
Rationale: Spironolactone is a potassium-retaining diuretic. If the client is also taking potassium chloride or another potassium supplement, the risk for hyperkalemia exists. Potassium doses need to be adjusted while the client is taking this medication. A dosage adjustment would not be necessary if the client was taking alprazolam, warfarin sodium, or verapamil hydrochloride.
Question 4 of 5
A client is being discharged from the hospital to home with an indwelling urinary catheter after the surgical repair of the bladder after trauma. The nurse determines that the client understands the principles of catheter management to prevent complications if the client states to follow which instruction?
Correct Answer: B
Rationale: Keeping the drainage bag lower than the bladder prevents urine backflow, reducing infection risk. The perineal area should be cleansed twice daily and after bowel movements. Adequate fluid intake is necessary to prevent infection, and coiling tubing under the thigh can obstruct drainage.
Question 5 of 5
A client with asthma is being admitted for breathing difficulties. His arterial blood gas results are pH 7.26, PCO2 49, PaO2 90, and HCO3- 21. Which of the following best describes this condition?
Correct Answer: A
Rationale: In this case, the client's arterial blood gas results show a pH of 7.26 and a PCO2 of 49, both of which are abnormal. A pH below the normal range of 7.35-7.45 indicates acidosis. The elevated PCO2 of 49 mmHg suggests respiratory acidosis as the primary issue. The normal range for PCO2 is 35-45 mmHg, so a value of 49 indicates the retention of excess CO2, leading to acidosis. The low HCO3- level of 21 also supports the presence of metabolic acidosis; however, the primary abnormality is respiratory, making this an uncompensated respiratory acidosis.
Therefore, the correct answer is 'Uncompensated respiratory acidosis.'
Choice B, 'Compensated respiratory alkalosis,' is incorrect because the client's pH is acidic, not alkalotic. Additionally, there is no compensation occurring for the primary respiratory acidosis indicated by the elevated PCO2.
Choice C, 'Uncompensated metabolic acidosis,' is incorrect because while the HCO3- level is low, the primary issue indicated by the elevated PCO2 is respiratory acidosis.
Choice D, 'Compensated metabolic alkalosis,' is incorrect since the arterial blood gas results do not support a metabolic alkalosis. The low HCO3- level would typically be seen in metabolic acidosis, but in this case, the primary issue is respiratory acidosis.