NCLEX-PN
Health Promotion and Maintenance NCLEX PN Questions Questions
Extract:
Question 1 of 5
Which of the following strategies should the nurse include when planning care for children of migrant workers?
Correct Answer: B
Rationale: When planning care for children of migrant workers, providing parents with copies of medical records is essential. This helps ensure continuity of care, especially as migrant families may move frequently. Immunizations should not be delayed due to acute illness; preventive care, including immunizations, should be provided even during acute illness visits to ensure the child stays up to date. While it is important to offer preventive services during routine visits, it is not ideal to provide them only during acute illness visits. Emphasizing the importance of having one primary care provider is valuable in healthcare, but it may not be feasible for migrant families due to their mobility.
Question 2 of 5
A nurse assisting with data collection is preparing to auscultate the client's bowel sounds. The client tells the nurse that he ate lunch just 45 minutes ago. On the basis of this information, which finding does the nurse expect to note?
Correct Answer: A
Rationale: Bowel sounds are high-pitched, gurgling, cascading sounds that occur irregularly between five and 30 times a minute. In this scenario, since the client ate lunch just 45 minutes ago, the nurse would expect to note gurgling sounds as normal bowel activity. Hypoactive sounds (low-pitched) or an absence of sounds are usually associated with conditions such as abdominal surgery or inflammation of the peritoneum, not with recent food intake.
Therefore, the correct answer is gurgling sounds, indicating normal bowel activity following a recent meal.
Question 3 of 5
When a woman is receiving postpartum epidural morphine, the nurse should plan to observe for which of the following side effects to occur within the first 3 hours?
Correct Answer: B
Rationale: A side effect of postpartum epidural morphine is the onset of itching within 3 hours of injection and lasting up to 10 hours. Nausea and vomiting might occur 4-7 hours after injection. Urinary retention is a side effect of postpartum epidural morphine but is not assessed as such within the first 3 hours. Somnolence is a rare side effect.
Question 4 of 5
Which of the following are included in the Rights of Medication Administration? Select all that apply.
Correct Answer: B
Rationale: The Rights of Medication Administration include the right client, right drug, right dose, right route, and right time. An additional right that is sometimes included is the right documentation. The correct answer includes the essential rights that must be ensured during medication administration.
Choice A is incorrect as 'right explanation' is not part of the traditional Rights of Medication Administration.
Choice B is incorrect as 'right explanation' is not included, and choice C is missing the right route.
Choice D is incorrect as it lacks the right dose and right route.
Question 5 of 5
Which of the following is not a nursing responsibility when preparing the client for central line insertion?
Correct Answer: A
Rationale: When preparing a client for central line insertion, nursing responsibilities include explaining the procedure to the client, ensuring necessary consents are signed according to the facility policy, and maintaining sterile technique when preparing the equipment and supplies. Advancing the guidewire is typically performed by the practitioner inserting the central line, not the nurse. It requires specialized training and expertise beyond the scope of nursing practice.
Therefore, the correct answer is advancing the guidewire. Option A is the correct answer because it delineates an activity that is not within the usual scope of nursing practice during central line insertion preparation. Options B, C, and D are incorrect as they reflect essential nursing responsibilities in this context.