NCLEX-PN
Health Promotion and Maintenance NCLEX Questions
1.
- A. Notify the registered nurse of the findings.
- B. Document the findings in the client's medical record.
- C. Recheck the vital signs in 1 hour.
- D. Continue collecting subjective and objective data.
Correct answer: A
Rationale:
2. After delivering a healthy newborn 1 hour ago, a nurse notes a woman's radial pulse rate is 55 beats/min. What action should the nurse take based on this finding?
- A. Reporting the finding to the healthcare provider immediately
- B. Helping the woman stay in bed and rest
- C. Documenting the finding
- D. Performing active and passive range-of-motion exercises
Correct answer: C
Rationale: After delivery, bradycardia (pulse rate 50-70 beats/min) may occur, reflecting the large amount of blood returning to the central circulation after delivery of the placenta. The increase in central circulation results in increased stroke volume, allowing a slower heart rate to provide adequate maternal circulation. A pulse rate of 55 beats/min falls within the normal range post-delivery, so there is no need to notify the healthcare provider immediately. It is important for the client to remain on bed rest in the immediate postpartum period to prevent complications. While range-of-motion exercises are beneficial for a client on bed rest, it is not the priority based on the data provided. Therefore, the most appropriate nursing action is to document the finding for accurate record-keeping and monitoring of the client's condition.
3. A nurse is assisting with data collection on the language development of a 9-month-old infant. Which developmental milestone does the nurse expect to note in an infant of this age?
- A. The infant babbles single consonants
- B. The infant babbles
- C. The infant says 'Mama.'
- D. The infant says 'Mama.'
Correct answer: D
Rationale: An 8- to 9-month-old infant can string vowels and consonants together. The first words, such as 'Mama,' 'Daddy,' 'bye-bye,' and 'baby,' begin to have meaning. A 1- to 3-month-old infant produces cooing sounds. Babbling is common in a 3- to 4-month-old. Single-consonant babbling occurs between 6 and 8 months of age. Therefore, the milestone of the infant saying 'Mama' is the most appropriate for a 9-month-old, indicating early language development. The other choices are developmentally inaccurate for a 9-month-old infant.
4. Which of the following foods is a complete protein?
- A. corn
- B. eggs
- C. peanuts
- D. sunflower seeds
Correct answer: B
Rationale: The correct answer is 'eggs.' Eggs are considered a complete protein as they contain all nine essential amino acids required by the body. On the other hand, corn, peanuts, and sunflower seeds are incomplete proteins, meaning they lack one or more of the essential amino acids needed by the body for optimal health. Corn, peanuts, and sunflower seeds are plant-based proteins that are deficient in one or more essential amino acids, unlike eggs, which are a high-quality complete protein source.
5. A nurse is assisting with developing a plan of care for an older client to help maintain an adequate sleep pattern. Which action should the nurse suggest be included in the plan?
- A. Encouraging bedtime reading or listening to music
- B. Encouraging at least one daytime nap
- C. Discouraging the use of a nightlight at bedtime
- D. Discouraging social interaction, particularly at bedtime
Correct answer: A
Rationale: To help maintain an adequate sleep pattern in older clients, it is essential to include activities that promote relaxation and a conducive sleep environment. Encouraging bedtime reading or listening to music can help the client unwind and prepare for sleep. Daytime naps should be discouraged to ensure a better nighttime sleep. Social interaction, especially positive interactions, can be beneficial and should not be discouraged. The use of a nightlight can create a safe and comfortable environment for the client, so it should not be discouraged unless specifically contraindicated.
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