a client complains that her skin is redder than normal the nurse notes the clients skin documents hyperemia and explains to the client that this condi
Logo

Nursing Elites

NCLEX-PN

Health Promotion and Maintenance NCLEX PN Questions

1. A client complains that her skin is redder than normal. The nurse notes the client's skin, documents hyperemia, and explains to the client that this condition is caused by which factor?

Correct answer: D

Rationale: Hyperemia is an excess of blood in a part of the body. The skin over a hyperemic area usually becomes reddened or warm. The condition is caused by increased blood flow, local relaxation of arterioles, or obstruction of the outflow of blood from an area. Choice A is incorrect because constriction of blood vessels would lead to decreased blood flow, not excess blood. Choice B is incorrect as an increased amount of bilirubin in the blood is related to jaundice, not hyperemia. Choice C is incorrect because increased perfusion of the surrounding tissues would cause redness, not hyperemia.

2. A client with Kawasaki disease has bilateral congestion of the conjunctivae, dry cracked lips, a strawberry tongue, and edema of the hands and feet followed by desquamation of fingers and toes. Which of the following nursing measures is most appropriate to meet the expected outcome of positive body image?

Correct answer: C

Rationale: Explaining the progression of the disease to the client and their family is the most appropriate nursing measure to promote a positive body image. By educating them about when symptoms are expected to improve and resolve, they can understand that there will be no permanent disruption in physical appearance that could negatively impact body image. While administering immune globulin intravenously may be part of the treatment for Kawasaki disease, it does not directly address body image concerns. Assessing the extremities for edema, redness, and desquamation every 8 hours is important for monitoring the disease but does not directly impact body image. Assessing heart sounds and rhythm is crucial for monitoring cardiac effects of Kawasaki disease but is not directly related to promoting a positive body image.

3. A nurse reviewing a client's record notes that the result of the client's latest Snellen chart vision test was 20/80. The nurse interprets the client's results in which way?

Correct answer: D

Rationale: When interpreting visual acuity testing results using the Snellen chart, the recorded numeric fraction represents the distance the client is standing from the chart and the distance a normal eye could read that particular line. A reading of 20/80 means that the client can read at 20 feet what a client with normal vision can read at 80 feet. This indicates visual impairment but does not meet the criteria for legal blindness, which is defined as best-corrected vision in the better eye of 20/200 or worse. Normal visual acuity is 20/20. Therefore, the correct interpretation is that the client can read at a distance of 80 feet what a client with normal vision can read at 20 feet. Choice A is incorrect because 20/80 does not meet the criteria for legal blindness. Choice B is incorrect as the client's vision is impaired. Choice C is incorrect because it reverses the interpretation of the fraction.

4. The nurse is observing a client self-administer two crushable medications through their G-tube. Which of the following would indicate a need for further instruction?

Correct answer: D

Rationale: The correct answer is that the client mixes their medications with their tube-feeding formula. Medications should not be mixed with tube-feeding formula or other medications as it may alter their effectiveness. The G-tube should be flushed before, between, and after the medications to prevent clogging and ensure proper administration. The client should remain in the Semi-Fowler's position for at least 30 minutes after medication administration to prevent reflux. Choice B is correct as it aligns with the proper post-administration positioning. Choices A and C are incorrect as flushing the G-tube before, between, and after medications, and mixing each medication separately in warm water are appropriate procedures that do not indicate a need for further instruction.

5. Which reported symptom(s) would indicate a client with Addison's disease has received too much fludrocortisone (Florinef) replacement?

Correct answer: B

Rationale: Fludrocortisone replacement in Addison's disease involves mimicking the action of aldosterone, a mineralocorticoid that causes the retention of sodium and water. Excessive retention of sodium and water can lead to weight gain. Therefore, a sudden increase in weight, especially a significant amount like 6 pounds in one week, can indicate an overdose of fludrocortisone. Choices A, C, and D are incorrect because oily skin and hair, loss of muscle mass, and increased blood glucose levels are not typically associated with excessive fludrocortisone replacement.

Similar Questions

All of the following are clinical manifestations indicating male climacteric except:
A nurse in the healthcare provider's office is checking the Babinski reflex in a 3-month-old infant. The nurse determines that the infant's response is normal if which finding is noted?
A community health nurse is providing information to a group of older clients about measures to decrease the risk of contracting influenza during peak flu season. The nurse should provide which information?
What is the primary focus of a case manager?
During a voice test, how should the nurse provide words for the client to repeat?

Access More Features

NCLEX PN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access

NCLEX PN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access

Other Courses