NCLEX-PN
Health Promotion and Maintenance NCLEX PN Questions Questions
Extract:
Question 1 of 5
When a woman is receiving postpartum epidural morphine, the nurse should plan to observe for which of the following side effects to occur within the first 3 hours?
Correct Answer: B
Rationale: A side effect of postpartum epidural morphine is the onset of itching within 3 hours of injection and lasting up to 10 hours. Nausea and vomiting might occur 4-7 hours after injection. Urinary retention is a side effect of postpartum epidural morphine but is not assessed as such within the first 3 hours. Somnolence is a rare side effect.
Question 2 of 5
A nurse assisting with data collection for a client with kidney failure notes that the client has the appearance of generalized edema over the entire body. The nurse documents this finding using which terminology?
Correct Answer: A
Rationale: The correct term for generalized edema over the entire body is 'Anasarca.' Anasarca is indicative of a systemic issue such as congestive heart failure or kidney failure. It does not refer to increased vascularity of the skin tissue. Ecchymosis is a bruise caused by capillary bleeding into the tissues, unrelated to generalized edema. Unilateral edema is swelling in a specific area of the body, not the generalized edema observed in anasarca.
Question 3 of 5
A laboring client is experiencing late decelerations. Which position should she be placed in?
Correct Answer: A
Rationale: The correct answer is the left lateral position. Placing the laboring client in the left lateral position is beneficial because it promotes blood flow to the placenta. Late decelerations indicate potential issues with fetal oxygenation, and changing the position to left lateral can help improve placental perfusion.
Choices B, C, and D are incorrect because lithotomy, semi-Fowler's, and right lateral positions do not specifically address the need for improved blood flow to the placenta in cases of late decelerations.
Question 4 of 5
A nurse sees documentation in the client's record indicating that the health care provider has noted the presence of adventitious breath sounds. The nurse knows that these types of sounds have which aspect?
Correct Answer: D
Rationale: Adventitious breath sounds are abnormal sounds that are not normally heard in the lungs. These sounds are added sounds superimposed on the breath sounds. They are caused by air colliding with secretions in the tracheobronchial passageways or when previously deflated airways pop open. Hollow sounds heard over the trachea and larynx are normal bronchial (tracheal) breath sounds, not adventitious. Rustling sounds heard over the peripheral lung fields are normal vesicular breath sounds, not adventitious.
Therefore, the correct answer is that adventitious breath sounds are abnormal sounds that should not be heard in the lungs.
Question 5 of 5
During a routine health screening, the nurse should talk to the parents of a 1-year-old child about which of the following?
Correct Answer: A
Rationale: During a routine health screening for a 1-year-old child, discussing the potential hazards of accidents is crucial. Accidents are the primary source of injury in children and can be life-threatening. Addressing appropriate nutrition now that the child has been weaned from breastfeeding should have already been discussed.
Toilet training is important but is typically addressed at a later age as one year is too early for this milestone. While preventing accidents in the house is important, focusing on the potential hazards of accidents in general is more comprehensive and critical for the child's safety.