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. A nurse provides instructions to an older adult about measures to prevent heatstroke. Which statement by the client indicates a need for further instruction?
- A. ''I should wear cool, light clothing in warm weather.''
- B. ''I need to wear a hat with a wide brim when I go outdoors.''
- C. ''I need to wear additional antiperspirant and deodorant in warm weather.''
- D. ''I should drink extra fluids during the summer.''
Correct answer: C
Rationale: As an individual ages, the number of sweat glands decreases, resulting in reduced body odor and decreased evaporative heat loss due to less sweating. The need for antiperspirants and deodorants is reduced in older adults. Therefore, the statement 'I need to wear additional antiperspirant and deodorant in warm weather' indicates a need for further instruction. Older adults should focus on wearing cool, light clothing in warm weather to prevent overheating, wearing a hat with a wide brim when outdoors to protect from the sun's rays, and staying hydrated by drinking extra fluids during the summer. These measures are more effective in preventing heatstroke in older adults compared to using additional antiperspirants and deodorants, which are not necessary.
3. When performing an abdominal assessment, what is the correct order of the tasks?
- A. inspect, percuss, palpate, auscultate
- B. inspect, palpate, percuss, auscultate
- C. inspect, auscultate, percuss, palpate
- D. inspect, palpate, auscultate, percuss
Correct answer: C
Rationale: The correct order of tasks when performing an abdominal assessment is to first inspect the abdomen visually, then auscultate to assess bowel sounds without altering them, followed by percussing to assess the presence of tympany or dullness, and finally palpating to feel for any tenderness, masses, or organ enlargement. Placing palpation or percussion before auscultation, as in choices A, B, and D, can affect the bowel sounds and examination findings, making them incorrect sequences.
4. While a client is on total parenteral nutrition, which of the following values should the nurse monitor closely?
- A. calcium
- B. magnesium
- C. glucose
- D. cholesterol
Correct answer: C
Rationale: Glucose should be monitored closely when a client is on total parenteral nutrition due to the high glucose concentration in the solutions. Monitoring glucose levels is crucial to prevent complications such as hyperglycemia or hypoglycemia. Calcium and magnesium are usually monitored to assess electrolyte imbalances, while cholesterol levels are not directly impacted by total parenteral nutrition. Therefore, choices A, B, and D are not the primary values that need close monitoring during total parenteral nutrition.
5. A school nurse provides information to the parents of school-age children regarding appropriate dental care. The nurse tells the parents that their children should perform which action?
- A. Brush and floss their teeth after meals and at bedtime
- B. Brush their teeth every morning and at bedtime and floss the teeth once a day, preferably at bedtime
- C. Brush their teeth every morning and at bedtime
- D. Brush and floss their teeth every morning and at bedtime
Correct answer: A
Rationale: School-age children are capable of taking responsibility for their own dental hygiene. Establishing good oral health habits during childhood can lead to a lifetime of cavity prevention. The nurse advises the parents that their children should brush with fluoride toothpaste and floss between their teeth after meals and before bedtime. This routine helps maintain good oral health and teaches children the importance of dental care. Choice A is the correct answer as it emphasizes both brushing and flossing after meals and at bedtime, which are crucial for effective dental care. Choices B, C, and D are incorrect as they do not stress the significance of both brushing and flossing after meals, which is essential for proper oral hygiene.
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