NCLEX-PN
Health Promotion and Maintenance NCLEX PN Questions
1. A nurse is preparing to auscultate for the presence of bowel sounds in a client who has just undergone surgery. The nurse places the stethoscope in which abdominal quadrant first?
- A. Left upper quadrant
- B. Left lower quadrant
- C. Right upper quadrant
- D. Right lower quadrant
Correct answer: D
Rationale: The correct answer is the right lower quadrant. The nurse starts auscultating in this quadrant at the ileocecal valve as bowel sounds are normally always present there. Then, the nurse proceeds to listen for bowel sounds in the other quadrants. Choices A, B, and C are incorrect as the initial placement of the stethoscope should be in the right lower quadrant to assess bowel sounds post-surgery.
2. Which of the following is least appropriate when caring for a stable postpartum client?
- A. Assess the location and height of the fundus.
- B. Conduct a family assessment, including the mother's future plans for returning to work, if applicable.
- C. Monitor the client for bleeding.
- D. Provide perineal care.
Correct answer: D
Rationale: Providing perineal care is not the least appropriate when caring for a stable postpartum client. Perineal care is essential for maintaining hygiene and preventing infection after delivery. Assessing the location and height of the fundus helps in monitoring postpartum uterine involution, which is crucial for assessing the recovery progress. Conducting a family assessment, including the mother's future plans for returning to work, is important for understanding the support system available for the mother during the postpartum period. Monitoring the client for bleeding is critical to promptly identify and address any postpartum hemorrhage. Therefore, providing perineal care is the least appropriate option among the choices provided as it is a fundamental aspect of postpartum care.
3. The nurse is assessing the dental status of an 18-month-old child. How many teeth should the nurse expect to examine?
- A. 6
- B. 8
- C. 12
- D. 16
Correct answer: C
Rationale: An 18-month-old child should have approximately 12 teeth. Children typically start getting teeth around 6 months of age. By subtracting 6 from the number of months in the child's age, you can calculate the expected number of teeth. For an 18-month-old child, 18 - 6 = 12 teeth. Therefore, the correct answer is 12 teeth. Choices A, B, and D are incorrect because they do not align with the expected dental development in an 18-month-old child.
4. A healthcare professional is using an otoscope to inspect the ears of an adult client. Which action does the professional take before inserting the otoscope?
- A. Pulling the pinna up and back
- B. Pulling the pinna down and forward
- C. Tipping the client's head down and toward the examiner
- D. Tipping the client's head down and away from the examiner
Correct answer: A
Rationale: In an adult client, the healthcare professional should pull the pinna up and back before inserting the otoscope. This action helps straighten the S shape of the ear canal, making it easier to insert the otoscope directly and comfortably. Tipping the client's head down and toward or away from the examiner is not the correct action when using an otoscope in an adult. Pulling the pinna down and forward is typically done when examining an infant or a child younger than 3 years old to straighten their ear canal for better visualization.
5. A nurse is providing information to a group of pregnant clients and their partners about the psychosocial development of an infant. Using Erikson's theory of psychosocial development, the nurse tells the group that infants have which developmental need?
- A. Must have needs ignored for short periods to develop a healthy personality
- B. Need to rely on the fact that their needs will be met
- C. Need to experience frustration, so it is best to allow an infant to cry for a while before meeting his or her needs
- D. Need to tolerate a great deal of frustration and discomfort to develop a healthy personality
Correct answer: B
Rationale: According to Erikson's theory of psychosocial development, infants struggle to establish a sense of basic trust rather than a sense of basic mistrust in their world, their caregivers, and themselves. If provided with consistent satisfying experiences that are delivered in a timely manner, infants come to rely on the fact that their needs are met and that, in turn, they will be able to tolerate some degree of frustration and discomfort until those needs are met. This sense of confidence is an early form of trust and provides the foundation for a healthy personality. Therefore, options A, C, and D are incorrect as they do not align with Erikson's theory that emphasizes the importance of infants trusting that their needs will be met.
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