NCLEX-PN
Health Promotion and Maintenance NCLEX PN Questions Questions
Extract:
Question 1 of 5
When examining the abdomen, a nurse auscultates before palpating and percussing the abdomen. The nurse performs the assessment in this manner for which reason?
Correct Answer: B
Rationale: When performing an abdominal assessment, the nurse auscultates the abdomen after inspection. Auscultation is done before palpation and percussion because these assessment techniques can increase peristalsis, which would yield a false interpretation of bowel sounds. This sequence helps prevent false interpretations of bowel sounds due to increased peristalsis caused by palpation and percussion. Options A, C, and D provide incorrect reasons for auscultating the abdomen before palpating and percussing it.
Question 2 of 5
A nurse is reviewing a patient's current Lithium levels. Which of the following values is outside the therapeutic range?
Correct Answer: D
Rationale: 1.0-1.2 mEq/L is considered standard therapeutic range for patient care.
Question 3 of 5
The LPN is about to give 100 mg Lopressor (metoprolol) to a client. Before administering the drug, they take the patient's vitals, which are as follows: Pulse: 58 Blood Pressure: 90/62 Respirations: 18/minute What action should the LPN take?
Correct Answer: D
Rationale: Lopressor is given to treat hypertension, and a pulse of 58 and a blood pressure of 90/62 are considered low.
To prevent the client from bottoming out, the drug should be held, and the findings reported to the RN, who should consult with the attending physician. LPNs should never adjust client dosing, as that is outside of their scope of practice. It is crucial to follow facility guidelines, which often recommend holding blood pressure medication at 60 bpm and a systolic pressure of 90 or less. By holding the drug and notifying the RN, the LPN ensures the client's safety and allows for appropriate assessment and decision-making by the healthcare team. Giving half the dose or double the dose without proper authorization can lead to serious complications and is considered unsafe practice.
Question 4 of 5
The client has an order for an IV piggyback of Ceftriaxone 750mg in 50mL D5W to run over 30 minutes. What is the appropriate drip rate?
Correct Answer: A
Rationale:
To calculate the drip rate, you need to convert the time from minutes to hours. The formula is (Volume to be infused / Time for infusion in minutes) x (60 minutes / 1 hour). Substituting the values, (50 mL / 30 min) x (60 min / 1 hr) = 100 mL/hr.
Therefore, the appropriate drip rate is 100 mL/hr.
Choices B, C, and D are incorrect as they do not match the calculated drip rate. Option A, 100 mL/hr, is the correct drip rate for administering Ceftriaxone 750mg in 50mL D5W over 30 minutes.
Question 5 of 5
When assessing the carotid artery of a client with cardiovascular disease, what action should a nurse perform?
Correct Answer: C
Rationale: When assessing the carotid artery of a client with cardiovascular disease, the nurse should listen to the carotid artery using the bell of the stethoscope to assess for bruits. This is crucial in detecting abnormal sounds that may indicate underlying pathology. Palpating the carotid artery in the upper third of the neck can trigger a vagal response, leading to a decrease in heart rate, which is undesirable. Palpating both arteries simultaneously can disrupt blood flow to the brain. Instructing the client to take slow, deep breaths is unnecessary and not a standard practice during carotid artery assessment.