a nurse listening to a clients chest to determine the quality of vocal resonance asks the client to repeat the word ninety nine as the nurse listens t
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Nursing Elites

NCLEX-PN

Health Promotion and Maintenance NCLEX PN Questions

1. When a nurse asks a client to repeat the word 'ninety-nine' while listening through the stethoscope and is able to hear the word clearly, which assessment finding is being documented?

Correct answer: C

Rationale: The nurse is documenting an abnormal bronchophony assessment finding. Bronchophony is a technique where the nurse asks the client to repeat a specific word, such as 'ninety-nine,' while listening through the stethoscope. Normally, the voice transmission is soft, muffled, and indistinct. However, if there is a pathologic condition increasing lung density, the nurse will hear the word clearly, indicating an abnormality. Vesicular breath sounds are normal sounds heard over peripheral lung fields and are not related to vocal resonance assessment. Egophony involves the client phonating a long 'ee-ee-ee-ee' sound, not repeating a specific word. Whispered pectoriloquy involves whispering a phrase like 'one-two-three,' not repeating a specific word. In these cases, normal findings are 'eeeeee' for egophony and a muffled, almost inaudible sound for whispered pectoriloquy.

2. Which of the following are included in the Rights of Medication Administration? Select all that apply.

Correct answer: B

Rationale: The Rights of Medication Administration include the right client, right drug, right dose, right route, and right time. An additional right that is sometimes included is the right documentation. The correct answer includes the essential rights that must be ensured during medication administration. Choice A is incorrect as 'right explanation' is not part of the traditional Rights of Medication Administration. Choice B is incorrect as 'right explanation' is not included, and choice C is missing the right route. Choice D is incorrect as it lacks the right dose and right route.

3. The teaching plan for a postpartum client who is about to be discharged should include which of the following instructions?

Correct answer: D

Rationale: The correct answer is to instruct the postpartum client to call the physician if their vaginal discharge becomes bright red. The vaginal discharge after birth is called lochia, and a return to red or containing clots could indicate impending hemorrhage or infection, necessitating notification of the physician. Choice A is incorrect because although some tenderness may be expected, redness and fatigue are clinical manifestations of mastitis, not normal postpartum changes. Choice B is also incorrect as increased frequency of urination after vaginal delivery could indicate a urinary tract infection, not a normal postpartum change. Choice C is incorrect because running a low-grade temperature for a few days is not expected postpartum; an elevated temperature above 100�F should be reported to the physician as it could indicate infection.

4. A nurse, assigned to care for a hospitalized child who is 8 years old, assists with planning care, taking into account Erik Erikson's theory of psychosocial development. According to Erikson's theory, which task represents the primary developmental task of this child?

Correct answer: B

Rationale: According to Erikson's theory of psychosocial development, the primary task for an 8-year-old child aligns with the stage of industry versus inferiority. This stage focuses on mastering useful skills and tools of the culture, emphasizing competence in various areas. Option A, 'Developing a sense of control over self and body functions,' is more characteristic of the toddler stage, emphasizing autonomy and self-regulation. Option C, 'Gaining independence from parents,' is more relevant to the adolescent stage, where identity development and autonomy become crucial. Option D, 'Developing a sense of trust in the world,' pertains to the infant stage, highlighting the importance of forming secure attachments. Therefore, the correct answer is B as it directly corresponds to the developmental tasks associated with an 8-year-old child according to Erikson's theory.

5. The LPN needs to determine the client's respiratory rate. What is the best technique to do this?

Correct answer: D

Rationale: The best technique to determine a client's respiratory rate is to count respirations while pretending to check the client's pulse. You should not inform the client that you are counting their respirations, as this might lead to a change in their breathing pattern. Pretending to check the pulse allows you to be close to the client without revealing that you are assessing their respiratory rate. Asking the client to sit still may not be as effective, as it may cause them to concentrate on their breathing. Watching from across the room may not provide an accurate assessment of respirations, as they might be difficult to observe.

Similar Questions

A pregnant client asks a nurse about the use of noninvasive acupressure as a complementary alternative therapy to relieve nausea. The nurse provides which instruction?
During a home visit, the LPN finds a client taking Amiodarone. Which statement by the client indicates an understanding of potential drug side effects?
A client with peripheral artery disease tells the nurse that pain develops in his left calf when he is walking and subsides with rest. The nurse documents that the client is most likely experiencing which disorder?
A client states, "I eat a well-balanced diet. I do not smoke. I exercise regularly, and I have a yearly checkup with my physician. What else can I do to help prevent cancer?"? The nurse should respond with which of the following statements?
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?

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