NCLEX-PN
Health Promotion and Maintenance NCLEX PN Questions
1. When performing an eye examination, which area can a healthcare provider best visualize using an ophthalmoscope?
- A. Iris
- B. Cornea
- C. Optic disc
- D. Conjunctiva
Correct answer: C
Rationale: An ophthalmoscope is a tool used to visualize the internal structures of the eye during an examination. The optic disc, located on the internal surface of the retina, can be best visualized using an ophthalmoscope. The iris, cornea, and conjunctiva are superficial structures that can be examined without the need for an ophthalmoscope. Therefore, the correct answer is the optic disc. Choices A, B, and D are incorrect because they are external structures that can be examined directly without the use of an ophthalmoscope.
2. The greatest time savers when planning client care include all of the following except:
- A. reacting to the crisis of the moment
- B. setting goals
- C. planning
- D. specifying priorities
Correct answer: A
Rationale: The greatest time-savers when planning client care are activities that facilitate focus and completion of priority items. Time-savers include setting goals, specifying priorities, planning tasks, delegating where appropriate, reassessment, and ongoing evaluation of needs. Reacting to the crisis of the moment is not a time-saving strategy in client care planning; it can lead to inefficiency, lack of focus, and potentially missing important priority items. Therefore, the correct answer is 'reacting to the crisis of the moment.' Choices B, C, and D are essential components for effective client care planning as they help in organizing and prioritizing tasks, setting objectives, and ensuring a structured approach to care delivery.
3. Which of the following are included in the Rights of Medication Administration? Select all that apply.
- A. Right dose, right time, right explanation, right client, right route
- B. Right dose, right time, right client, right route
- C. Right dose, right time, right client
- D. Right time, right explanation, right client
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.
4. The nurse is caring for a female client who has recently been diagnosed with cancer and will soon begin chemotherapy. Which of these statements would require additional follow-up and education?
- A. I will be most susceptible to an infection between 7 and 12 days after chemotherapy.
- B. I should try to get my annual teeth cleaning in before beginning chemotherapy.
- C. I should wait until all my hair falls out to purchase a wig.
- D. I should try to drink 8-10 glasses of water a day.
Correct answer: C
Rationale: This client is at risk for altered body image due to chemotherapy-induced hair loss. A wig can assist in coping with this change. It is advisable for the client to shop for a wig before hair loss occurs to better match color and style. Waiting until all hair falls out may lead to stress and limited options in finding a suitable wig. Choices A, B, and D are accurate. Understanding the timing of susceptibility to infection, maintaining oral health before chemotherapy, and staying hydrated are important aspects of care during chemotherapy. Therefore, the statement 'I should wait until all my hair falls out to purchase a wig' requires additional follow-up and education.
5. A community health nurse is instructing a group of female clients about breast self-examination (BSE). The nurse instructs the clients to perform the examination in which manner?
- A. At the onset of menstruation
- B. Every month during ovulation
- C. Weekly, at the same time of day
- D. One week after menstruation begins
Correct answer: D
Rationale: Breast self-examination (BSE) should be performed after the menstrual period, specifically on the seventh day of the menstrual cycle, when the breasts are smallest and least congested. This timing facilitates the easier detection of any abnormalities. Performing BSE at the onset of menstruation (Option A) can lead to false results due to hormonal changes affecting breast tissue. Performing it every month during ovulation (Option B) is not recommended as breast tissue may be more tender and lumpy during this time. Conducting weekly examinations at the same time of day (Option C) is unnecessary and can lead to unnecessary anxiety for the client.
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