NCLEX-PN
Health Promotion and Maintenance NCLEX PN Questions
1. When preparing to assist the healthcare provider in examining a client's skin with the use of a Wood light, what action should the nurse perform?
- A. Darken the room
- B. Obtain informed consent from the client
- C. Obtain a scalpel and a slide for diagnostic evaluation
- D. Obtain medication to anesthetize the skin area before proceeding with the examination
Correct answer: A
Rationale: When using a Wood light during a skin examination, the room should be darkened to enhance the visibility of fluorescence. The Wood light emits long-wavelength ultraviolet light, highlighting certain skin conditions. Darkening the room aids in better visualization. Obtaining informed consent is a crucial aspect of healthcare but not directly related to using a Wood light. Obtaining a scalpel and a slide is unnecessary for a noninvasive Wood light examination. Anesthetizing the skin area is not required as the procedure is painless and noninvasive.
2. What is the most appropriate intervention for a client with suspected genitourinary trauma and visible blood at the urethral meatus?
- A. Insertion of a Foley catheter.
- B. In-and-out catheter specimen for urinalysis.
- C. A voided urine specimen for urinalysis.
- D. A urologist consult.
Correct answer: D
Rationale: A urologist consult is the most appropriate intervention for a client with visible blood at the urethral meatus and suspected genitourinary trauma. This specialist can evaluate the extent of the trauma and provide the necessary treatment. Foley catheter insertion (Choice A) and in-and-out catheter specimen for urinalysis (Choice B) are contraindicated in the presence of genitourinary trauma as they can worsen the injury. While a voided urine specimen for urinalysis (Choice C) may be ordered by the physician, it does not address the specific management needed for genitourinary trauma. Therefore, a urologist consult is the best option in this scenario.
3. Ms. Petty is having difficulty falling asleep. Which of the following measures promote sleep?
- A. exercising vigorously for 20 minutes each night beginning at 9:30 p.m.
- B. taking a cool shower and drinking a hot cup of tea
- C. watching TV nightly until midnight
- D. getting a back rub and drinking a glass of warm milk
Correct answer: D
Rationale: The correct answer is getting a back rub and drinking a glass of warm milk. These measures are relaxation techniques that can help promote sleep by calming the body and mind. Exercising vigorously right before bedtime, as mentioned in choice A, can increase arousal and make it harder to fall asleep. Choice B, taking a cool shower and drinking a hot cup of tea, involves temperature changes that might not be conducive to sleep. Watching TV until midnight, as in choice C, exposes the individual to blue light and mental stimulation, both of which can disrupt the natural sleep-wake cycle.
4. 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.
5. The LPN is taking care of a client who is on Phenelzine (Nardil) for depression. Which meal would the nurse encourage the client to avoid?
- A. steak and potatoes
- B. prosciutto and cheese plate
- C. orange juice and toast
- D. carbonated water, shrimp and rice
Correct answer: B
Rationale: The correct answer is 'prosciutto and cheese plate.' Phenelzine (Nardil) is an MAOI (Monoamine Oxidase Inhibitor), and clients on these drugs should avoid foods high in tyramine due to the risk of dangerous elevations in blood pressure. Prosciutto and aged cheeses are examples of foods rich in tyramine, so they should be avoided. Choices A, C, and D do not contain high levels of tyramine and are considered safe to consume while on Phenelzine.
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