NCLEX-RN
Health Promotion and Maintenance NCLEX RN Questions
1. A client is preparing to undergo a cystoscopy for stones. Which of the following statements indicates that the client understands the procedure?
- A. I better drink a lot of fluid now because I won't be able to after the test.
- B. I will probably see a little blood when I urinate.
- C. I will be able to go home after 3 days in the hospital.
- D. I won't need any pain medicine; this probably will not hurt.
Correct answer: B
Rationale: The correct answer is, 'I will probably see a little blood when I urinate.' During a cystoscopy, a scope is inserted into the client's bladder to inspect structures or remove objects like stones. This procedure is usually performed under local or general anesthesia. It is common for clients to experience a small amount of blood in their urine (hematuria) or have pink-colored urine after the procedure. The other choices are incorrect because drinking a lot of fluid before the test, staying in the hospital for 3 days, and assuming no pain will be experienced are not accurate statements related to a cystoscopy procedure.
2. Which of the following abides by the Americans with Disabilities Act of 1990?
- A. A nurse manager cannot cancel an interview with a potential employee because he has left-sided paralysis
- B. A nurse is allowed to have a leave of absence to recover after a back injury
- C. A nurse is mandated to receive 12 weeks off of work after having a baby
- D. A nurse manager must hire a nurse who uses a walker for mobility
Correct answer: A
Rationale: The Americans with Disabilities Act of 1990 prohibits discrimination against individuals with disabilities in employment practices, ensuring equal opportunities for qualified individuals. Therefore, a nurse manager cannot cancel an interview with a potential employee simply because the individual has left-sided paralysis. Doing so would be considered discriminatory under the ADA. Choices B, C, and D do not directly align with ADA requirements. Choice B involves medical leave, which can be covered under a different law; choice C refers to maternity leave, which is protected under other regulations; and choice D involves a hiring decision based on a mobility aid, not the individual's qualifications, which does not fall under ADA guidelines.
3. You are attempting to teach the wife of a Greek patient how to administer his gastrostomy tube feedings once he returns home. She smiles and nods through your explanations, but when you ask her for a return demonstration, she looks confused and shakes her head. Her daughter enters the room and states that she does not speak English. What would be most helpful in this situation?
- A. Teach the daughter instead
- B. Teach both and ask the daughter to translate for you
- C. Contact a home health agency to provide care
- D. Provide a pamphlet with detailed instructions
Correct answer: B
Rationale: Teaching both the patient's wife and the daughter is the best option in this situation. The daughter may not always be available, and the wife is eager to care for her husband at home. While a hospital interpreter is often preferred, asking the daughter to interpret is a good alternative. This approach allows the daughter to receive instruction and reinforce it for herself as she translates it to her mother. Contacting a home health agency may not be necessary if family members are willing and able to assist. Providing a pamphlet with detailed instructions would not be as effective in ensuring the wife fully understands the procedure and can carry it out correctly.
4. You are turning your patient in bed and notice that a confused and lethargic patient had loose car keys and lipstick in the bed and had been lying on them. What is this person at risk for due to all three of these factors: confusion, lethargy, and items in the bed?
- A. Falls
- B. Skin breakdown
- C. Apnea
- D. Lack of mobility
Correct answer: B
Rationale: This patient is at great risk for skin breakdown due to the presence of three specific risk factors: confusion, lethargy, and items in the bed. While confusion puts the patient at risk for falls, confusion and lethargy together may lead to a lack of mobility. However, skin breakdown is the primary concern in this scenario as it is associated with all three risk factors - confusion, lethargy, and the presence of items in the bed. Therefore, the correct answer is 'Skin breakdown'.
5. Mary T. was admitted to a nursing home on May 1st. On July 4th, she was diagnosed with a skin infection. This infection is considered a ________________ infection.
- A. nosocomial
- B. systemic
- C. resident flora
- D. resident aura
Correct answer: A
Rationale: The correct answer is 'nosocomial.' A nosocomial infection is defined as one that is not present upon admission to a healthcare facility but instead occurs during the patient's stay. In this case, since Mary was diagnosed with a skin infection after being admitted to the nursing home, it is considered a nosocomial infection. Nosocomial infections are a significant concern in healthcare settings, and infection control measures are in place to prevent their spread. Choices B, C, and D are incorrect. 'Systemic' refers to a condition affecting the entire body, not specific to a healthcare setting. 'Resident flora' and 'resident aura' are not commonly used terms in healthcare and do not relate to infections acquired in healthcare facilities.
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