NCLEX-RN
Health Promotion and Maintenance NCLEX RN Questions Questions
Extract:
Question 1 of 5
Which action by the client should lead the nurse to determine the need for further teaching regarding the use of the incentive spirometer?
Correct Answer: B
Rationale: Incentive spirometry is ineffective if the client breathes through the nose. The client should exhale, form a tight seal around the mouthpiece, inhale slowly, hold to the count of 5, and remove the mouthpiece to exhale. The client should repeat the exercise approximately 10 times every hour for best results.
Question 2 of 5
A client in labor has an electronic fetal monitor attached to the abdomen, and the nurse notes that the baby's heart rate slows down during each contraction, returning to normal limits only after the contraction is complete. Which type of fetal heart rate change does this pattern describe?
Correct Answer: B
Rationale: Late decelerations refer to a pattern where the baby's heart rate decreases during contractions and does not return to normal until after the contraction ends. This is considered a non-reassuring sign as it indicates potential fetal distress. Late decelerations are associated with uteroplacental insufficiency, and immediate medical attention is required. Variable decelerations (
Choice
A) are abrupt, unpredictable decreases in the fetal heart rate, usually associated with cord compression. Early decelerations (
Choice
C) are usually benign and mirror the contraction pattern. Accelerations (
Choice
D) are reassuring signs of fetal well-being, characterized by an increase in the fetal heart rate.
Question 3 of 5
A client has a right-sided chest tube with 50 cc of serosanguinous fluid in the collection chamber and air bubbles are collecting in the water seal chamber. What is the most appropriate action for the nurse to take at this time?
Correct Answer: C
Rationale: The water seal of a chest tube acts as a one-way valve. Air bubbles in the water seal indicate a leak between the client and the chamber. The nurse should briefly clamp the tube near the client's chest to locate the source of the leak. Once identified, the nurse should unclamp the tubing and notify the physician immediately.
Choice A is incorrect because air bubbles in the water seal chamber are not a normal finding and indicate a leak.
Choice B is incorrect as stripping the tubing could aggravate the issue and is not the initial appropriate action.
Choice D is incorrect as it does not address the immediate need to locate and address the leak.
Question 4 of 5
A school nurse is performing screening examinations for scoliosis. Which signs of scoliosis should the nurse assess for? Select all that apply.
Correct Answer: A,C,F
Rationale: Scoliosis is a lateral curvature of the spine.
To ensure early detection and treatment, children aged 9 through 15 years should be screened for scoliosis; those at greatest risk are girls from 10 years of age through adolescence. The child should be unclothed or wearing only underpants so that the chest, back, and hips can be clearly seen. The child should stand with the weight equally on both feet, legs straight, and arms hanging loosely at the sides. The nurse then observes for the signs of scoliosis. These signs include nonpainful lateral curvature of the spine, a curve with one turn (C curve) or two compensating curves (S curve), lateral deviation and rotation of each vertebra, unequal shoulder heights, unequal waist angles, unequal rib prominences and chest asymmetry, and unequal rib heights.
Question 5 of 5
Mr. N is a client who entered the hospital with a diagnosis of diabetic ketoacidosis. The nurse enters his room to check his vital signs and finds him breathing at a rate of 32 times per minute; his respirations are deep and regular. Which type of respiratory pattern is Mr. N most likely exhibiting?
Correct Answer: A
Rationale: Mr. N is exhibiting Kussmaul respirations, characterized by rapid, deep, and regular breathing. This type of respiratory pattern is commonly seen in metabolic acidosis, such as in diabetic ketoacidosis. Kussmaul respirations are a form of hyperventilation, leading to the elimination of carbon dioxide from the body.
Choice B, Cheyne-Stokes respirations, is characterized by alternating periods of deep, rapid breathing followed by periods of apnea and is not typically associated with diabetic ketoacidosis.
Choice C, Biot's respirations, involve irregular breathing patterns with periods of apnea and are not reflective of the described breathing pattern. Cluster breathing, as mentioned in
Choice D, is not a recognized term in respiratory patterns and does not describe the breathing pattern observed in Mr. N.