NCLEX-PN
Health Promotion and Maintenance NCLEX PN Questions
1. Which of the following statements, if made by the parents of a newborn, does not indicate a need for further teaching about cord care?
- A. "I should put alcohol on my baby's cord 3-4 times a day."?
- B. "I should put the baby's diaper on so that it covers the cord."?
- C. "I should call the physician if the cord becomes dark."?
- D. "I should wash my hands before and after I take care of the cord."?
Correct answer: A
Rationale: Explanation: Parents should be taught that putting alcohol or other antimicrobials on the cord is no longer recommended for cord care. This can interfere with the natural healing process and may increase the risk of irritation or infection. Washing hands before and after providing cord care is essential to prevent the transfer of pathogens. Placing the baby's diaper below the cord allows it to be exposed to air and promotes drying, reducing the risk of infection. It is normal for the cord to turn dark as it dries, so calling the physician only if the cord becomes red, swollen, or has discharge is appropriate. Therefore, the statement '"I should put alcohol on my baby's cord 3-4 times a day."?' indicates a need for further teaching about cord care.
2. A client who is immobilized secondary to traction is complaining of constipation. Which of the following medications should the nurse expect to be ordered?
- A. Advil
- B. Anasaid
- C. Clinocil
- D. Colace
Correct answer: D
Rationale: The correct answer is Colace. Colace is a stool softener that helps relieve constipation by drawing more water into the bowel, making the stool softer and easier to pass. This is beneficial for an immobilized client as it can help prevent constipation due to decreased mobility. Options A, B, and C (Advil, Anasaid, Clinocil) are not indicated for constipation relief. Advil and Anasaid are nonsteroidal anti-inflammatory drugs used for pain relief, while Clinocil is a fictional medication.
3. The mother of an adolescent calls the clinic nurse and reports that her daughter wants to have her navel pierced. The mother asks the nurse about the dangers associated with body piercing. The nurse provides which information to the mother?
- A. Infection always occurs when body piercing is done
- B. Hepatitis B is a concern with body piercing
- C. Body piercing is generally harmless as long as it is performed under sterile conditions
- D. It is important to discourage body piercing because of the risk of contracting human immunodeficiency virus (HIV)
Correct answer: C
Rationale: Generally, body piercing is harmless if the procedure is performed under sterile conditions by a qualified person. Some complications that may occur include bleeding, infection, keloid formation, and the development of allergies to metal. It is essential to clean the area at least twice a day (more often for a tongue piercing) to prevent infection. HIV and hepatitis B infections are not typically associated with body piercing; however, they are a possibility with tattooing. Choice A is incorrect because infection does not always occur when body piercing is done. Choice B is not the best answer as hepatitis B is not commonly associated with body piercing. Choice D is incorrect because the risk of contracting HIV is not a significant concern with body piercing if performed under sterile conditions.
4. All of the following are common reasons that nurses are reluctant to delegate except:
- A. lack of self-confidence.
- B. desire to maintain authority.
- C. confidence in subordinates.
- D. getting trapped in the 'I can do it better myself' mindset.
Correct answer: C
Rationale: The correct answer is 'confidence in subordinates.' If a delegator has confidence in their subordinates' abilities, they are more likely to delegate tasks. Reasons why nurses are reluctant to delegate include their own lack of self-confidence, the desire to maintain authority, and getting trapped in the 'I can do it better myself' mindset. Therefore, having confidence in subordinates is not a common reason for reluctance to delegate.
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?
- A. Document the finding
- B. Palpate the area for a mass
- C. Notify the healthcare provider
- D. Percuss the abdomen to check for tympany
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.
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