NCLEX-RN
Health Promotion and Maintenance NCLEX RN Questions Questions
Extract:
Question 1 of 5
Which nursing intervention is most appropriate to maintain the patency of a client's nasogastric tube?
Correct Answer: B
Rationale: The correct answer is to irrigate the tube as per physician's order. A client with a nasogastric tube is at risk of the tube kinking or clotting off, which can lead to complications such as abdominal distention or vomiting.
To ensure the patency of the tube, the nurse should follow the physician's orders and facility policy to irrigate the tube with water or a solution as needed. Maintaining a constant connection to low-intermittent suction (
Choice
A) is not typically done to maintain tube patency. Suctioning the mouth and nose every shift (
Choice
C) is not directly related to maintaining nasogastric tube patency. Performing a daily fecal occult blood sample (
Choice
D) is unrelated to maintaining the patency of a nasogastric tube.
Question 2 of 5
Mrs. M has had diabetes for seven years. She has worked hard to control her blood glucose levels and watch her dietary intake. Her physician orders a hemoglobin A1C test. Which of the following best describes the action of this test?
Correct Answer: D
Rationale: A hemoglobin A1C test, also known as a glycated hemoglobin test, determines the amount of hemoglobin that is coated with glucose. Excess glucose in the bloodstream may cause it to attach to hemoglobin on red blood cells. Because the life of these cells is between 2 and 3 months, the hemoglobin A1C is an accurate measurement of a client's glucose during that time.
Choices A, B, and C are incorrect.
Choice A relates to anemia and iron supplements, which are not assessed by a hemoglobin A1C test.
Choice B mentions excess glucose in the urine, which is typically assessed through a urine glucose test, not the hemoglobin A1C test.
Choice C is incorrect as the test is not related to the amount of hemoglobin reaching the liver to support gluconeogenesis; instead, it specifically measures the amount of hemoglobin that is glycated or coated with glucose.
Question 3 of 5
Clonazepam has been prescribed for the client, and the nurse teaches the client about the medication. Which statement by the client indicates that further teaching is necessary?
Correct Answer: A
Rationale: Clonazepam is a benzodiazepine. Clients who experience signs/symptoms of toxicity with the administration of clonazepam exhibit slurred speech, sedation, confusion, respiratory depression, hypotension, and eventually coma. Some drowsiness may occur, but it will decrease with continued use. The medication may be taken with food to decrease gastrointestinal irritation. The medication may be taken at bedtime if drowsiness does occur. Slurred speech indicates toxicity and should be reported immediately, not expected to disappear in 8 weeks.
Question 4 of 5
A healthcare professional is preparing to insert an indwelling catheter in a female client. Which of the following positions of the client is most appropriate for this procedure?
Correct Answer: C
Rationale: When preparing to insert an indwelling catheter for a female client, the most appropriate position is the dorsal recumbent position. In this position, the client lies on their back with knees bent. This position allows for easy access to the urethral area for catheter insertion. The lithotomy position, with legs elevated and spread apart, is more invasive and typically used for gynecological exams. The prone position, lying face down, is not suitable for catheter insertion. High Fowler's position, sitting upright at a 90-degree angle, is not ideal for catheter insertion as it does not provide proper access to the perineal area.
Question 5 of 5
Which of the following situations might warrant a laboratory magnesium level?
Correct Answer: C
Rationale: Ulcerative colitis can lead to symptoms such as abdominal pain, fever, diarrhea, and weight loss. This condition may impact the absorption of certain nutrients, including magnesium.
Therefore, patients with chronic gastrointestinal conditions like ulcerative colitis should be screened for electrolyte imbalances related to impaired digestion. Hyperthyroidism, arthritis, and depression do not typically directly affect magnesium levels in the same way as gastrointestinal conditions like ulcerative colitis.