NCLEX-PN
Health Promotion and Maintenance NCLEX Questions
1. A nurse notes the presence of variable decelerations on the fetal heart rate monitor strip and suspects cord compression. The nurse should immediately perform which action?
- A. Insert a gloved finger into the mother's vagina to feel for cord compression
- B. Position the mother so that her hips are elevated
- C. Notify the registered nurse
- D. Perform a vaginal examination on the mother
Correct answer: B
Rationale: When variable decelerations on the fetal heart rate monitor strip suggest cord compression, the immediate action the nurse should take is to reposition the mother to alleviate the compression. Elevating the mother's hips or changing her position can help shift the fetal presenting part and relieve pressure on the cord. This action aims to improve or resolve the variable decelerations. Contacting the registered nurse may be necessary, but it is not the immediate action required in this situation. Performing a vaginal examination is contraindicated due to the potential risk of further compromising blood flow through the umbilical cord. Inserting a gloved finger into the mother's vagina to feel for the cord is also not recommended as it poses a similar risk of exacerbating the situation.
2. A nurse is supervising a student in preparing the physical environment for an interview with a client. Which action by the student is correct?
- A. Setting the room temperature at a comfortable level
- B. Placing a chair for the client across from the nurse's desk
- C. Providing seating for the client so that the client faces a strong light
- D. Setting up seating so that the client and nurse are not at eye level
Correct answer: A
Rationale: When preparing the physical environment for an interview with a client, it is crucial to ensure the client's comfort. Setting the room temperature at a comfortable level is essential for the client's well-being. Additionally, providing privacy, sufficient lighting, and removing distractions are crucial factors. It is recommended to maintain a distance of around 4 to 5 feet between the client and the nurse. Seating should be arranged so that the client and nurse are at eye level to facilitate effective communication and prevent barriers. Placing a chair across from the nurse's desk may create a physical barrier, positioning the client to face a strong light can be uncomfortable and distracting, and setting up seating so that the client and nurse are not at eye level may impede effective communication.
3. The client provides information to a pregnant client who is experiencing nausea and vomiting about measures to relieve the discomfort. Which statement by the mother indicates the need for further information?
- A. ''I should eat five or six small meals a day rather than three full meals.''
- B. ''I need to be sure not to drink liquids with my meals.''
- C. ''I should keep dry crackers at my bedside and eat them before I get out of bed in the morning.''
- D. ''I need to avoid eating fried or greasy foods.''
Correct answer: B
Rationale: To alleviate nausea and vomiting, the client should avoid drinking liquids with meals. The client should keep dry crackers at her bedside, avoid fried foods, and eat smaller meals. Additionally, the client should eat dry crackers every 2 hours to prevent an empty stomach and avoid spicy foods and foods with strong odors, such as onion and cabbage. The incorrect choices are: A) Eating five or six small meals a day instead of three full meals is a correct recommendation. C) Keeping dry crackers at her bedside and eating them before getting out of bed in the morning is a helpful suggestion. D) Avoiding fried or greasy foods is a valid advice to alleviate nausea and vomiting.
4. When teaching parents how their children learn sex role identification, the nurse should include which of the following statements?
- A. Sex role identification begins in infancy.
- B. Sex role identification begins in the preschool years.
- C. Sex role identification begins during the school-age years.
- D. Sex role identification begins during early adolescence.
Correct answer: A
Rationale: Sex role identification begins during infancy as infants can identify body parts by the end of the first year. Preschoolers often engage in masturbation and sex play. School-age children continue to develop awareness of their sexual identity, including behaviors like hugging and kissing. Early adolescence sees further development influenced by sexual maturation and experimentation with sex roles. Therefore, the correct statement is that sex role identification begins in infancy. Choices B, C, and D are incorrect as they misrepresent the timeline of the development of sex role identification in children.
5. What is a chemical reaction between drugs before their administration or absorption known as?
- A. a drug incompatibility
- B. a side effect
- C. an adverse event
- D. an allergic response
Correct answer: A
Rationale: A chemical reaction between drugs before their administration or absorption is termed a drug incompatibility. This phenomenon commonly occurs when drug solutions are mixed before intravenous administration but can also happen with orally administered drugs. Choices B, C, and D are incorrect because side effects, adverse events, and allergic responses typically occur after the drugs have been administered and absorbed, not before.
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