NCLEX-RN
Health Promotion and Maintenance NCLEX RN Questions Questions
Extract:
Question 1 of 5
While caring for a client in labor, a nurse attaches an electronic fetal monitor to the client's abdomen to assess the baby's heart rate. The nurse observes that the baby's heart rate slows down during each contraction and does not return to normal limits until after the contraction is complete. What type of fetal heart rate change does this pattern describe?
Correct Answer: B
Rationale: Late decelerations are characterized by the baby's heart rate declining in utero during contractions. The heart rate drops below baseline and stays low until after the contraction ends. Late decelerations are concerning as they indicate uteroplacental insufficiency, which can compromise fetal oxygenation. This pattern is a non-reassuring sign and requires immediate intervention. Variable decelerations are typically abrupt decreases in heart rate, often associated with cord compression. Early decelerations, on the other hand, mirror the contractions and are considered benign, resulting from fetal head compression. Accelerations are reassuring signs of fetal well-being, indicating a responsive and healthy fetal nervous system.
Question 2 of 5
The nurse monitors a client for brachial plexus compromise after shoulder arthroplasty and is checking the status of the ulnar nerve. Which technique should the nurse use to assess the status of this nerve?
Correct Answer: B
Rationale: So that the nurse may assess the ulnar nerve status, the client is asked to spread all of the fingers wide and resist pressure. Weakness against pressure may indicate compromise of the ulnar nerve. Raising the forearm above the head assesses the flexion of the biceps and determines the status of the cutaneous nerve. Moving the thumb toward the palm and back describes the assessment of the status of the radial nerve. Having the client grasp the nurse's hand and assessing the strength of the first 2 fingers describes the assessment of the status of the medial nerve.
Question 3 of 5
The nurse is providing teaching to a client newly diagnosed with hypertension. The nurse knows that the client understands the teaching when the client selects which menu option?
Correct Answer: B
Rationale: Baked chicken and fresh green beans are low-sodium, suitable for hypertension. Other options are high in sodium.
Question 4 of 5
A client who is taking an antipsychotic medication is preparing for discharge. To facilitate health promotion for this client, what instruction should the nurse provide?
Correct Answer: A
Rationale: Antipsychotic medications improve the thought processes and behaviors of a client with psychotic symptoms, especially a client with schizophrenia. Photosensitivity is a side effect of antipsychotic medications. Maintaining a strict tyramine-restricted diet is applicable to monoamine oxidase inhibitors (MAOIs). Antipsychotics are not used to treat depression. Lithium is a mood stabilizer that requires monitoring of medication blood levels.
Question 5 of 5
A postpartum nurse has instructed a new mother regarding how to bathe her newborn. The nurse demonstrates the procedure to the mother and, on the following day, asks the mother to perform the procedure. Which observation by the nurse indicates that the mother is performing the procedure correctly?
Correct Answer: B
Rationale: Bathing should start at the eyes and face and with the cleanest area first. Next, the external ears and behind the ears are cleaned. The newborn infant's neck should be washed because formula, lint, and breast milk will often accumulate in the folds of the neck. The hands and arms are then washed. The newborn infant's legs are washed next, with the diaper area being washed last.