NCLEX-PN
Health Promotion and Maintenance NCLEX Questions
1. A rubella titer is performed on a pregnant client, and the results indicate a titer of less than 1:8. The nurse provides the client with which information?
- A. She must have been exposed to the rubella virus at some point in her life.
- B. The test will need to be repeated during the pregnancy.
- C. She has not developed immunity to the rubella virus.
- D. The test results are normal.
Correct answer: B
Rationale: A rubella titer of less than 1:8 indicates that the client is not immune to rubella. In such cases, retesting will be necessary during the pregnancy. If the client is found to be non-immune, rubella immunization is required post-delivery. Therefore, choices A, C, and D are incorrect. Choice A suggests exposure, which cannot be confirmed by the titer result. Choice C wrongly implies that the client has not developed immunity, which is not accurate. Choice D is incorrect as the titer result is not within the normal immune range.
2. When educating an obese client about nutritional needs and weight loss, which of the following should not be included?
- A. knowledge of food and food products
- B. development of a positive mental attitude
- C. adequate exercise
- D. starting a fast weight-loss diet
Correct answer: D
Rationale: When educating an obese client about nutritional needs and weight loss, it is important to cover factors such as knowledge of food and food products, the development of a positive mental attitude, and the importance of adequate exercise. These aspects contribute to a holistic approach to weight management. However, recommending the client to start a fast weight-loss diet should not be included. Fast weight-loss diets can be harmful, leading to health risks, nutrient deficiencies, and unsustainable outcomes. It is crucial to advocate for gradual, sustainable weight loss strategies to ensure long-term success and overall well-being. Therefore, starting a fast weight-loss diet is the least appropriate option among the choices provided.
3. How often should the nurse change the intravenous tubing on total parenteral nutrition solutions?
- A. every 24 hours
- B. every 36 hours
- C. every 48 hours
- D. every 72 hours
Correct answer: A
Rationale: The correct answer is 'every 24 hours.' Changing the intravenous tubing on total parenteral nutrition solutions every 24 hours is crucial due to the high risk of bacterial growth. Bacterial contamination can lead to serious infections in patients receiving total parenteral nutrition. Choices B, C, and D are incorrect because waiting longer intervals between tubing changes increases the risk of bacterial contamination and infection, compromising patient safety. It is essential to maintain a strict 24-hour schedule to minimize the risk of complications associated with bacterial contamination.
4. How should a client's neck be positioned for palpation of the thyroid?
- A. flexed toward the side being examined
- B. hyperextended directly backward
- C. flexed away from the side being examined
- D. flexed directly forward
Correct answer: A
Rationale: The correct way to position a client's neck for palpation of the thyroid is to have it flexed toward the side being examined. This positioning helps to better access and palpate the thyroid gland. Option B, hyperextending the neck directly backward, is incorrect as it can make palpation more difficult and uncomfortable for the client. Option C, flexing the neck away from the side being examined, is also incorrect as it may obscure the thyroid gland, making it harder to palpate. Option D, flexing the neck directly forward, is not ideal for thyroid palpation as it does not provide the best access to the gland.
5. A laboring client is experiencing late decelerations. Which position should she be placed in?
- A. left lateral
- B. lithotomy
- C. semi-Fowler's
- D. right lateral
Correct answer: A
Rationale: The correct answer is the left lateral position. Placing the laboring client in the left lateral position is beneficial because it promotes blood flow to the placenta. Late decelerations indicate potential issues with fetal oxygenation, and changing the position to left lateral can help improve placental perfusion. Choices B, C, and D are incorrect because lithotomy, semi-Fowler's, and right lateral positions do not specifically address the need for improved blood flow to the placenta in cases of late decelerations.
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