NCLEX-PN
Health Promotion and Maintenance NCLEX Questions Questions
Extract:
Question 1 of 5
Which of the following arterial blood gas values indicates a patient may be experiencing a condition of metabolic acidosis?
Correct Answer: B
Rationale: The bicarbonate value is below normal (15, normal range 22-26 mEq/L), indicating a condition of metabolic acidosis.
Question 2 of 5
After delivering a healthy newborn 1 hour ago, a nurse notes a woman's radial pulse rate is 55 beats/min. What action should the nurse take based on this finding?
Correct Answer: C
Rationale: After delivery, bradycardia (pulse rate 50-70 beats/min) may occur, reflecting the large amount of blood returning to the central circulation after delivery of the placenta. The increase in central circulation results in increased stroke volume, allowing a slower heart rate to provide adequate maternal circulation. A pulse rate of 55 beats/min falls within the normal range post-delivery, so there is no need to notify the healthcare provider immediately. It is important for the client to remain on bed rest in the immediate postpartum period to prevent complications. While range-of-motion exercises are beneficial for a client on bed rest, it is not the priority based on the data provided.
Therefore, the most appropriate nursing action is to document the finding for accurate record-keeping and monitoring of the client's condition.
Question 3 of 5
A client is pregnant for the sixth time. She tells the nurse that she has had three elective first-trimester abortions and that she has a son who was born at 40 weeks' gestation and a daughter who was born at 36 weeks' gestation. In calculating the gravidity and para (parity), the nurse determines that the client is:
Correct Answer: B
Rationale: The term gravida refers to the number of pregnancies, of any duration, that a woman has had. Parity (para) refers to the number of pregnancies that have progressed past 20 weeks at delivery.
Therefore, this client is gravida 6 (pregnant for the sixth time), para 2 (has a son and a daughter). In this case, the correct answer is Gravida 6, para 2.
Choices A, C, and D are incorrect as they do not accurately reflect the information provided. Pregnancy outcomes are often described using the GTPAL acronym: gravida (G), term births (T), preterm births (P), abortions (
A), and live births (L). Applying this to the client's history, the GTPAL would be G = 6, T = 1, P = 1, A = 3, L = 2, which further confirms the correct answer.
Question 4 of 5
A pregnant client is scheduled to undergo a transabdominal ultrasound, and the nurse provides information to the client about the procedure. The nurse provides which information?
Correct Answer: B
Rationale: The correct answer is that the client may need to drink fluids before the test and may not void until the test has been completed. For a transabdominal ultrasound, the woman is positioned on her back with her head elevated and turned slightly to one side to prevent supine hypotension. A wedge or rolled blanket is placed under one hip to help her maintain this position comfortably. If a full bladder is necessary, the woman is instructed to drink several glasses of clear fluid 1 hour before the test and told that she should not void until the test has been completed. Warm mineral oil or transmission gel is spread over her abdomen, and the sonographer slowly moves a transducer over the abdomen to obtain a picture. The procedure typically takes 10 to 30 minutes, making choice A incorrect.
Choice C is incorrect because a probe is not inserted into the vagina for a transabdominal ultrasound.
Choice D is incorrect because the woman is positioned on her back with her head elevated and turned slightly to one side, not specifically on her back.
Question 5 of 5
A nurse assisting with data collection is preparing to auscultate for bowel sounds. The nurse should use which technique?
Correct Answer: A
Rationale:
To auscultate for bowel sounds, the nurse should use the diaphragm end piece of the stethoscope as bowel sounds are relatively high pitched. The stethoscope should be held lightly against the skin to avoid stimulating more bowel sounds. The nurse should begin in the right lower quadrant at the ileocecal valve, where bowel sounds are normally present. It is recommended to listen for 5 minutes before deciding that bowel sounds are absent to ensure a thorough assessment.
Choice B is incorrect because the bell end is used for low-pitched sounds such as heart sounds.
Choice C is incorrect as holding the stethoscope firmly and deeply can cause unnecessary bowel sound stimulation.
Choice D is incorrect as listening for 1 minute is insufficient to determine the presence or absence of bowel sounds.