NCLEX-PN
Health Promotion and Maintenance NCLEX PN Questions
Extract:
Question 1 of 5
When a client with a major burn experiences body image disturbance, which of the following is an appropriate nursing intervention classification?
Correct Answer: A
Rationale: Grief work facilitation helps address body image disturbance in burn clients by supporting grief resolution related to altered appearance.
Question 2 of 5
The gag reflex test assesses which cranial nerves?
Correct Answer: A
Rationale: Gagging during the gag reflex test indicates that cranial nerves IX and X (the glossopharyngeal and vagus nerves) are intact.
Question 3 of 5
A client has just returned from surgery where a femoral-popliteal bypass was performed. The nurse has assessed the client and is unable to feel a pulse at either the dorsalis pedis or the posterior tibial sites of the left foot. The foot feels warm and the color is pink. What action should the nurse perform next to prevent ischemia?
Correct Answer: B
Rationale: The nurse should immediately obtain a Doppler device and recheck the pulses. The dorsalis pedis and posterior tibial can be difficult to assess and might need to be verified with a Doppler. Because the client just had a surgery in which a complication is arterial insufficiency, the client must be monitored carefully. If the pulses are not found, the nurse should recognize that this is an emergent situation, and the physician must be notified immediately. If the nurse waits 30 minutes before determining if the pulses can be felt, this could compromise the viability of the client's foot due to ischemia. Documenting the findings is important but must be performed after the nurse locates the dorsalis pedis and posterior tibial pulses or any necessary interventions are made.
Question 4 of 5
A nurse reviewed the arterial blood gas reading of a 25 year-old male. The nurse should be able to conclude the patient is experiencing which of the following conditions?
Correct Answer: D
Rationale: Respiratory alkalosis is indicated by elevated pH and low carbon dioxide levels, with no compensation noted.
Question 5 of 5
In hanging a parenteral IV fluid that is to be infused by gravity, rather than with an infusion pump, the nurse notes that the IV tubing is available in different drop factors. Which tubing is a microdrop set?
Correct Answer: B
Rationale: All microdrop sets are calculated to give 60 drops for each milliliter of IV fluid. Macrodrop sets are calculated to give 10, 15, or 20 drops for each milliliter of IV fluid.