NCLEX-RN
Health Promotion NCLEX RN Exam Questions Questions
Extract:
Question 1 of 5
Using Naegele's Rule, calculate the estimated date of birth for a client who reports the first day of the last menstrual period was August 7.
Correct Answer: B
Rationale: Naegele's Rule: Add 1 year, subtract 3 months, add 7 days. August 7 + 1 year = August 7 next year; minus 3 months = May 7; plus 7 days = May 14.
Question 2 of 5
A client is receiving lipids (fat emulsion) intravenously at home, and the client's spouse manages the infusion. The home care nurse makes a visit and discusses potential side and adverse effects of the therapy with the client and the spouse. After the discussion, the nurse expects the spouse to verbalize that, in case of a suspected adverse effect, which action is the priority?
Correct Answer: A
Rationale: Signs/symptoms of an adverse effect to lipids (fat emulsion) include chest and back pain, chills, vertigo, cyanosis, diaphoresis, dyspnea, fever, flushing, headache, nausea and vomiting, and thrombophlebitis of the vein. The priority action is to stop the infusion to limit the adverse response. Although contacting the nurse, taking the client's blood pressure, and contacting the local emergency response team are correct interventions, the priority is to stop the infusion.
Question 3 of 5
A client who sustained a thoracic cord injury a year ago returns to the clinic for a follow-up visit, and the nurse notes a small reddened area on the coccyx. The client is not aware of the reddened area. After counseling the client to relieve pressure on the area by adhering to a turning schedule, which action by the nurse is most appropriate?
Correct Answer: C
Rationale: The client should be encouraged to be as independent as possible. The most effective means of skin self-assessment for this client is with the use of a mirror. The redness cannot be felt. Asking a family member to assess the skin daily does not promote independence. It is unnecessary and unrealistic for the client to return to the clinic daily for a skin check.
Question 4 of 5
The nurse is monitoring a client diagnosed with type 1 diabetes mellitus. Today's blood work reveals a glycosylated hemoglobin level of 10%. The nurse creates a teaching plan based on the understanding that this result indicates which finding?
Correct Answer: D
Rationale: Glycosylated hemoglobin is a measure of glucose control during the 6 to 8 weeks before the test. It is a reliable measure for determining the degree of glucose control in diabetic clients over a period of time, and it is not influenced by dietary management 1 to 2 days before the test is done. The glycosylated hemoglobin level should be 6.0% or less for a client diagnosed with diabetes mellitus, with elevated levels indicating poor glucose control.
Question 5 of 5
Which should the nurse identify as a situational crisis?
Correct Answer: A,C,F
Rationale: A situational crisis arises from an external rather than an internal source and often is unanticipated. Examples of external situations that can precipitate a situational crisis include divorce, the loss of a job, the death of a loved one, an abortion, a change in job, a change in financial status, and severe physical or mental illness. A maturational crisis occurs at a developmental stage; examples include marriage, the birth of a child, and retirement. An adventitious crisis, or crisis of disaster, is not a part of everyday life and is unplanned or accidental. This type of crisis can result from a natural disaster (flood, fire, earthquake), a national disaster (acts of terrorism, war, riots, airplane crashes), or a crime of violence (rape, assault, murder, bombing, spousal or child abuse).