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. Client self-determination is the primary focus of:
- A. malpractice insurance.
- B. nursing's advocacy for clients.
- C. confidentiality.
- D. health care.
Correct answer: B
Rationale: Client self-determination is the primary focus of nursing's advocacy for clients. Nurses advocate for their clients' right to autonomy and self-determination, ensuring that the clients' preferences and choices are respected. Confidentiality, on the other hand, involves maintaining the privacy of the client and their information. Health care is a broad term encompassing various aspects of medical services. Malpractice insurance is a type of insurance that provides coverage for professionals in case of negligence or malpractice, not directly related to client self-determination.
3. A pregnant client is scheduled to undergo a transabdominal ultrasound, and the nurse provides information to the client about the procedure. The nurse provides which information?
- A. The procedure typically takes 10 to 30 minutes.
- B. She may need to drink fluids before the test and may not void until the test has been completed.
- C. A probe coated with gel will be inserted into the vagina.
- D. She will be positioned on her back, with her head elevated and turned slightly to one side.
Correct answer: B
Rationale: The correct answer is that the client may need to drink fluids before the test and may not void until the test has been completed. For a transabdominal ultrasound, the woman is positioned on her back with her head elevated and turned slightly to one side to prevent supine hypotension. A wedge or rolled blanket is placed under one hip to help her maintain this position comfortably. If a full bladder is necessary, the woman is instructed to drink several glasses of clear fluid 1 hour before the test and told that she should not void until the test has been completed. Warm mineral oil or transmission gel is spread over her abdomen, and the sonographer slowly moves a transducer over the abdomen to obtain a picture. The procedure typically takes 10 to 30 minutes, making choice A incorrect. Choice C is incorrect because a probe is not inserted into the vagina for a transabdominal ultrasound. Choice D is incorrect because the woman is positioned on her back with her head elevated and turned slightly to one side, not specifically on her back.
4. A nurse in the emergency department is assisting with data collection of a client. The presence of which condition would cause the nurse to avoid testing range of motion (ROM) of the cervical spine?
- A. Headache
- B. Neck trauma
- C. Sinus infection
- D. Muscle spasms
Correct answer: B
Rationale: A nurse assisting with data collection for a client should avoid testing the range of motion (ROM) of the cervical spine if the client has neck trauma. Neck trauma may have resulted in a cervical fracture, and further movement of the neck could lead to spinal cord injury. Testing ROM does not need to be avoided for headache, sinus infection, or muscle spasms as these conditions do not pose the same risk of exacerbating a potential cervical injury. Therefore, the correct answer is neck trauma.
5. In a community pediatric health clinic, which developmental task should you apply into your practice?
- A. You should apply the principles of initiative when caring for preschool children.
- B. You should apply the principles of sensorimotor thought when caring for preschool children.
- C. You should apply the principles of intimacy when caring for the adolescent.
- D. You should apply the principles of concrete operations when caring for the adolescent.
Correct answer: A
Rationale: When working in a community pediatric health clinic, applying the principles of initiative is crucial when caring for preschool children. According to Erik Erikson's psychosocial theory, the developmental task for preschool children is initiative. Preschool children are in the stage where they are eager to initiate activities and carry out tasks. This stage is characterized by a balance between initiative and guilt. By encouraging children to explore and take the initiative in a supportive environment, healthcare providers can foster their sense of independence and creativity. The other choices are incorrect because: - Sensorimotor thought is a term associated with Jean Piaget's cognitive development theory, not Erikson's psychosocial theory. - Intimacy is a developmental task associated with young adults, not adolescents, in Erikson's theory. - Concrete operations is a term linked to Piaget's theory of cognitive development and is not a developmental task according to Erikson's psychosocial theory.
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