NCLEX-RN
Health Promotion and Maintenance NCLEX RN Questions Questions
Extract:
Question 1 of 5
Which of the following conditions increases a client's risk of aspiration of stomach contents?
Correct Answer: A
Rationale: A client in restraints is at an increased risk of aspiration of stomach contents. When a client is restrained, they may be unable to effectively move or turn their body if they begin to vomit, which can lead to aspiration. This lack of mobility can hinder their ability to protect their airway. On the other hand, a scaphoid abdomen, which is sunken or hollowed, is not a direct risk factor for aspiration. Additionally, lying prone, facing downward, does not necessarily increase the risk of aspiration, as aspiration is more likely when lying supine (facing upward).
Therefore, the correct answer is that a client is in restraints.
Question 2 of 5
The nurse is caring for a client with a non-rebreather mask. Which is the priority nursing action when caring for this client?
Correct Answer: B
Rationale: Adjusting the flow rate to keep the reservoir bag inflated ensures adequate oxygen delivery, the primary goal of a non-rebreather mask.
Question 3 of 5
Percussion is a physical assessment technique that is used to identify which findings?
Correct Answer: A,B,C,F
Rationale: Percussion involves tapping the body with the fingertips to evaluate the size, borders, and consistency of body organs and assess for fluid in body cavities. Through percussion, the location, size, and density of an underlying structure can be determined. Through palpation, assessment is done via the sense of touch. Measurements of specific physical signs, including resistance, resilience, roughness, texture, and mobility, can be made through palpation.
Question 4 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 5 of 5
When a blood pressure cuff is too wide for a client's arm, what type of reading might this blood pressure cuff produce?
Correct Answer: B
Rationale: When a blood pressure cuff is too wide for a client's arm, it may produce an abnormally low blood pressure reading. This occurs because the oversized cuff can lead to an underestimation of blood pressure. It is essential to ensure that the cuff fits appropriately to obtain an accurate reading. An abnormally high reading (
Choice
C) is less likely with an oversized cuff, as it generally leads to lower readings. A normal reading (
Choice
A) is unlikely due to the inaccuracies caused by the oversized cuff. A fluctuating reading (
Choice
D) is not a typical result of using a cuff that is too wide; instead, it usually leads to consistently low readings.