NCLEX-RN
Health Promotion and Maintenance NCLEX RN Questions Questions
Extract:
Question 1 of 5
Which of the following situations warrants a measurement for orthostatic hypotension?
Correct Answer: C
Rationale: The correct answer is a 58-year-old female with near-syncope. Orthostatic hypotension is a drop in blood pressure of greater than 20 mmHg systolic when moving from a sitting or lying position to standing. Patients at higher risk include those with syncope or near-syncope, symptomatic hypovolemia, and those prone to falls. The other choices are less likely to present with orthostatic hypotension. A spinal injury, altered mental status, and acute deep vein thrombosis are not directly associated with the immediate need for orthostatic hypotension measurement.
Question 2 of 5
A client with hyperkalemia may exhibit peaked T waves on an electrocardiogram. This manifestation is an early sign of high potassium levels, but the diagnosis should not be based on this aspect alone. Untreated, hyperkalemia can lead to progressively worsening cardiac instability.
Correct Answer: B
Rationale: A lumbar puncture is performed to obtain cerebrospinal fluid for analysis to investigate various conditions affecting the client. During the procedure, the client is typically positioned on their side or sitting leaning over a table with their back rounded. The physician inserts a needle into the back around the L4-L5 vertebrae to collect the sample. Option A is incorrect because a lumbar puncture does not draw blood but instead collects cerebrospinal fluid. Option C is incorrect as the client should not necessarily lie flat for 24 hours post-procedure. Option D is incorrect as the common risks of a lumbar puncture include headache, back pain, and potential infection, not nausea, rash, or hypotension.
Question 3 of 5
The nurse is teaching a client the proper technique for using a cane. Which statements should the nurse include in the teaching? Select all that apply.
Correct Answer: B,C
Rationale: The cane is held on the unaffected side and moved with the affected leg to provide support. The cane is held closer to the body, not 8-10 inches away.
Question 4 of 5
A client is diagnosed with organic erectile dysfunction and the nurse is collecting subjective data from the client. After the assessment, the nurse explains to the client that which are causes of this disorder?
Correct Answer: C,D,E,F
Rationale: Erectile dysfunction is the inability to achieve or maintain an erection for sexual intercourse. Organic erectile dysfunction is a gradual deterioration of function; the man first notices diminishing firmness and a decrease in frequency of erections. Causes include inflammation of the prostate, urethra, or seminal vesicles; surgical procedures such as prostatectomy; pelvic fractures or lumbosacral injuries; vascular diseases, including hypertension; chronic neurological conditions such as Parkinson's disease or multiple sclerosis; endocrine disorders such as diabetes mellitus or thyroid disorders; smoking and alcohol consumption; drugs; and poor overall health. Functional (not organic) erectile dysfunction usually has a psychological cause.
Question 5 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.