NCLEX-PN
Health Promotion and Maintenance NCLEX Questions Questions
Extract:
Question 1 of 5
What is the most appropriate initial action for a newborn infant with low blood glucose?
Correct Answer: C
Rationale: The blood glucose level for a newborn infant should remain greater than 40 mg/dL to prevent permanent brain damage. When dealing with low blood glucose in a newborn, the most appropriate initial action is to contact the registered nurse. The nurse will obtain prescriptions regarding feeding the infant with low blood glucose and follow agency policies on feeding infants in such conditions. It is common practice to feed the infant if the glucose level is 40 mg/dL or less. Asking the registered nurse to draw another blood sample in 2 hours and repeating the test is not the most appropriate immediate action, as timely intervention is crucial in this situation. Contacting the healthcare provider may cause unnecessary delays since the registered nurse is usually the first point of contact for immediate actions in this scenario. Documenting the results in the newborn's medical record is essential, but it is not the initial step in managing low blood glucose in a newborn.
Question 2 of 5
A nurse assisting with data collection is preparing to auscultate for bowel sounds. The nurse should use which technique?
Correct Answer: A
Rationale:
To auscultate for bowel sounds, the nurse should use the diaphragm end piece of the stethoscope as bowel sounds are relatively high pitched. The stethoscope should be held lightly against the skin to avoid stimulating more bowel sounds. The nurse should begin in the right lower quadrant at the ileocecal valve, where bowel sounds are normally present. It is recommended to listen for 5 minutes before deciding that bowel sounds are absent to ensure a thorough assessment.
Choice B is incorrect because the bell end is used for low-pitched sounds such as heart sounds.
Choice C is incorrect as holding the stethoscope firmly and deeply can cause unnecessary bowel sound stimulation.
Choice D is incorrect as listening for 1 minute is insufficient to determine the presence or absence of bowel sounds.
Question 3 of 5
After breast reconstruction secondary to breast cancer, the nurse should recognize which of the following expected client outcomes as evidence of a favorable response to nursing interventions related to disturbed body image?
Correct Answer: C
Rationale: The correct answer is 'restored body integrity.' This outcome is crucial in addressing disturbed body image following breast reconstruction. Restored body integrity reflects a positive perception of one's body after surgery, contributing to improved body image.
Choices A, 'maintaining adequate tissue perfusion,' are more related to physiological outcomes and are not directly linked to body image concerns.
Choice B, 'demonstrating behaviors that reduce fears,' is associated with anxiety management, not body image.
Choice D, 'remaining free of infection,' pertains to preventing infections and does not directly address body image concerns.
Question 4 of 5
When working with multicultural populations, the nurse should consider all of the following when planning care for a client with an altered sexuality pattern except:
Correct Answer: A
Rationale: When working with multicultural populations, it is essential to understand cultural variations in beliefs and practices related to sexuality. While it is true that some cultures view the postpartum period as a state of impurity and that some women in the African-American culture view childbearing as a validation of their femaleness, the statement 'some Hispanic and Native-American cultures are very open when discussing sexuality' is incorrect. In reality, many cultures, including Hispanic and Native-American cultures, are sometimes hesitant to discuss sexuality. For example, some Navajos, Hispanics, and Orthodox Jews may consider the postpartum period as impure, leading to seclusion of women until the end of bleeding, marked by a ritual bath. Additionally, many Native-American women believe in the importance of monthly menstruation for physical well-being and harmony.
Therefore, the statement about Hispanic and Native-American cultures being very open about discussing sexuality is not accurate in the context of working with multicultural populations.
Question 5 of 5
To improve overall health, the nurse should place the highest priority on assisting a client to make lifestyle changes for which of the following habits?
Correct Answer: A
Rationale:
To improve overall health, the nurse should prioritize assisting the client in making lifestyle changes that have the most significant impact on health. Drinking a six-pack of beer each day can have serious negative effects on health, including liver damage, increased risk of chronic diseases, and addiction. By addressing this habit first, the nurse can make a substantial positive difference in the client's health. Eating an occasional chocolate bar, exercising twice a week, and using relaxation exercises to deal with stress are beneficial habits, but they are not as detrimental to health as excessive alcohol consumption.
Therefore, they are not the highest priority for immediate lifestyle changes to improve health.