NCLEX-RN
Health Promotion and Maintenance NCLEX RN Questions Questions
Extract:
Question 1 of 5
The nurse is teaching a client with atrial fibrillation about the need to begin long-term anticoagulant therapy. Which explanation should the nurse use to best describe the reasoning for this therapy?
Correct Answer: D
Rationale: In atrial fibrillation, the quivering atria cause sluggish blood flow, leading to clot formation along the heart wall, which can dislodge and cause pulmonary or cerebral emboli. Options A, B, and C inaccurately describe the mechanism requiring anticoagulation.
Question 2 of 5
A client returns from surgery after having a colon resection. The nurse is performing an assessment and notes the wound edges have separated. This condition is called:
Correct Answer: C
Rationale: Wound dehiscence occurs when the edges of a wound pull apart. The condition may occur following a surgical procedure if the sutures were deficient. Wound dehiscence may also occur following a wound infection or in cases where a client significantly stretches or overuses the associated tissues. Evisceration refers to the protrusion of internal organs through an open wound. Hematoma is a localized collection of blood outside the blood vessels. Granulation is the formation of new connective tissue and tiny blood vessels on the surface of a wound during the healing process.
Question 3 of 5
Which of the following interventions is necessary before insertion of an arterial line into the radial artery?
Correct Answer: C
Rationale: Before inserting an arterial line into the radial artery, it is crucial to perform an Allen test. The Allen test assesses the collateral circulation to the hand by compressing both the radial and ulnar arteries. By occluding the radial artery and releasing the ulnar artery, the nurse can check if the ulnar artery can adequately supply blood to the hand if the radial artery is cannulated. This step ensures that there is adequate circulation to the hand post-insertion of the arterial line.
Choice A, ensuring that the client does not need surgery, is not directly related to the insertion of an arterial line and is not a necessary step before the procedure.
Choice B, assessing grip strength, is not specific to the vascular status of the hand and does not provide information about the adequacy of collateral circulation.
Choice D, checking a serum potassium level, is unrelated to the assessment of radial artery patency and collateral circulation, which are the primary concerns before arterial line insertion.
Question 4 of 5
The community health nurse has reviewed information about the population of a local community and has determined that there are groups in the population that are at high risk for infection with tuberculosis (TB). The nurse targets which high-risk group for screening?
Correct Answer: C
Rationale: Older clients in long-term-care facilities are at high risk for TB due to age-related immune decline and close living conditions. French Canadians, White Anglo-Saxon Americans, and adolescents are not specifically high-risk groups unless other factors apply.
Question 5 of 5
The OR nursing staff are preparing a client for a surgical procedure. The anesthesiologist has given the client medications, and the client has entered the induction stage of anesthesia. The nursing staff can expect which of the following symptoms and activities from the client during this time?
Correct Answer: D
Rationale: During the induction stage of anesthesia, the client may exhibit symptoms like euphoria, drowsiness, or dizziness. This stage occurs after the administration of medications by the anesthesiologist and ends when the client loses consciousness.
Choice A is incorrect as irregular breathing patterns are not typically associated with the induction stage.
Choice B is incorrect as minimal heartbeat and dilated pupils are not commonly observed during this stage.
Choice C is incorrect as relaxed muscles, regular breathing, and constricted pupils are not indicative of the induction stage of anesthesia.