NCLEX-PN
Health Promotion and Maintenance NCLEX PN Questions Questions
Extract:
Question 1 of 5
While assisting with data collection on a client, a nurse hears a bruit over the abdominal aorta. What action should the nurse prioritize based on this finding?
Correct Answer: C
Rationale: Detection of a bruit over the aorta during abdominal assessment may indicate the presence of an aneurysm. The nurse's priority action should be to notify the healthcare provider to further evaluate the situation. Palpating the area or percussing the abdomen could potentially increase the risk of an aneurysm rupture. While documenting the finding is important, the priority is to ensure timely intervention by involving the healthcare provider.
Question 2 of 5
During a voice test, how should the nurse provide words for the client to repeat?
Correct Answer: B
Rationale: During a voice test, the nurse should whisper words from the client's side at a distance of 1 to 2 feet from the ear being tested. This distance helps prevent transmission around the head and ensures accurate testing of one ear at a time. By standing close to the client and whispering, the nurse prevents lip-reading and compensatory actions by the client. The client with normal hearing should be able to repeat each word correctly.
Choices A, C, and D are incorrect.
Choice A is wrong as the voice should be whispered, not spoken in a soft tone.
Choice C is inaccurate because a distance of 10 feet is too far for precise testing.
Choice D is incorrect as whispering from a distance of 20 feet would not effectively test the client's hearing.
Question 3 of 5
Which of the following clients should refrain from therapy with the thiazide diuretic hydrochlorothiazide (HCTZ)?
Correct Answer: C
Rationale: Thiazides can elevate blood glucose by causing hypokalemia, which reduces insulin secretion, making them unsuitable for clients with type II diabetes.
Question 4 of 5
The LPN is about to give 100 mg Lopressor (metoprolol) to a client. Before administering the drug, they take the patient's vitals, which are as follows: Pulse: 58 Blood Pressure: 90/62 Respirations: 18/minute What action should the LPN take?
Correct Answer: D
Rationale: Lopressor is given to treat hypertension, and a pulse of 58 and a blood pressure of 90/62 are considered low.
To prevent the client from bottoming out, the drug should be held, and the findings reported to the RN, who should consult with the attending physician. LPNs should never adjust client dosing, as that is outside of their scope of practice. It is crucial to follow facility guidelines, which often recommend holding blood pressure medication at 60 bpm and a systolic pressure of 90 or less. By holding the drug and notifying the RN, the LPN ensures the client's safety and allows for appropriate assessment and decision-making by the healthcare team. Giving half the dose or double the dose without proper authorization can lead to serious complications and is considered unsafe practice.
Question 5 of 5
During a home visit, the LPN finds a client taking Amiodarone. Which statement by the client indicates an understanding of potential drug side effects?
Correct Answer: B
Rationale: The correct answer is B. Amiodarone can cause increased photosensitivity, making it essential for the client to wear sunblock when exposed to sunlight.
Choice A is incorrect because numbing or tingling in the feet is not a common side effect of Amiodarone.
Choice C is unrelated as the drug does not typically require supplemental vitamin B12.
Choice D is also incorrect as there is no need to avoid leafy vegetables specifically due to Amiodarone.