NCLEX-RN
Free NCLEX RN Questions on Health Promotion and Maintenance Questions
Extract:
Question 1 of 5
When preparing the client with a spinal cord injury who is experiencing bladder spasms and reflex incontinence for discharge to home, the nurse should provide which instruction to prevent the problem?
Correct Answer: A
Rationale: Caffeine in the diet can contribute to bladder spasms and reflex incontinence; thus, it should be eliminated in the diet of the client with a spinal cord injury. The self-monitoring of the temperature is useful to detect infection, but it does nothing to alleviate bladder spasms. Limiting fluid intake does not prevent spasm, and it could place the client at further risk for urinary tract infection. Self-catheterization every 2 hours is too frequent and serves no useful purpose.
Question 2 of 5
Cyclophosphamide is prescribed for the client diagnosed with breast cancer, and the nurse provides instructions to the client regarding the medication. Which statement by the client indicates the need for further teaching?
Correct Answer: C
Rationale: Cyclophosphamide can cause hemorrhagic cystitis, requiring copious fluid intake (2–3 liters/day) to prevent it, not fluid restriction. Hair regrowth, reporting sore throat (indicating infection), and avoiding live virus vaccine contacts are correct due to immunosuppression.
Question 3 of 5
The clinic nurse provides home care instructions to a mother regarding the care of her child who is diagnosed with croup. Which statement by the mother indicates the need for further instructions?
Correct Answer: B
Rationale: The mother needs to be instructed that cough syrup and cold medicines should not be administered because they may dry and thicken secretions, worsening croup symptoms. Acetaminophen (Tylenol) is appropriate for reducing fever. Sips of warm fluids help relax the vocal cords and thin mucus. A cool-mist humidifier is recommended to keep the air moist and reduce airway irritation.
Question 4 of 5
The nurse is preparing to care for the mother of a preterm infant. When should the nurse plan to begin discharge planning?
Correct Answer: C
Rationale: Discharge planning begins at admission of the preterm infant. The determination of the services, needs, supplies, and equipment requirements should not be made on the day of discharge. Beginning planning during labor is incorrect because the outcome of the delivery is not known. At discharge or when the parents feel comfortable caring for their infant are incorrect because these times are much too late to make the plans that need to be made.
Question 5 of 5
The nurse provides home care instructions to a client diagnosed with Cushing's syndrome. The nurse determines that the client understands the hospital discharge instructions if the client makes which statement?
Correct Answer: B
Rationale: Cushing's syndrome results in an increased secretion of cortisol. Cortisol stimulates the secretion of gastric acid, and this can result in the development of peptic ulcers and gastrointestinal bleeding. The client should be encouraged to eat potassium-rich foods to correct the hypokalemia that occurs with this disorder. Cushing's syndrome does not affect temperature changes in the lower extremities. Aspirin can increase the risk for gastric bleeding and skin bruising.