NCLEX-PN
Health Promotion and Maintenance NCLEX Questions
1. A preschooler has successfully completed the test item 'counts 5 blocks' on the Denver II test. This pass is evidence of which of the following developmental concepts?
- A. centration
- B. causality
- C. nonreversibility
- D. conservation
Correct answer: D
Rationale: The ability of a preschooler to move five blocks to a piece of paper and state there are five blocks on the paper is evidence that the preschooler has the ability of conservation. This concept refers to the fact that the quantity of something doesn't change just because the shape, contour, and so on has changed. Five blocks are still five blocks, whether they are lying beside the paper, stacked on the paper, or moved to the paper. Centration is the ability to concentrate on one feature of a situation while neglecting all other aspects. Causality is based on the sequence of events, one event ordinarily following another. Non-reversibility refers to the inability of preschoolers to reverse their operations. They are only able to think forward, not retrace or reverse their thought processes.
2. 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.
3. A 4-year-old client is unable to go to sleep at night in the hospital. Which nursing intervention best promotes sleep for the child?
- A. turning out the room light and closing the door
- B. tiring the child during the evening with quiet activities
- C. identifying the child's home bedtime rituals and following them
- D. encouraging visitation by friends during the evening
Correct answer: C
Rationale: For a 4-year-old client struggling to sleep in the hospital, it is essential to identify and replicate their home bedtime rituals. This familiarity can provide comfort and promote better sleep. Turning out the room light and closing the door (Choice A) might increase the child's fear by plunging the room into darkness, making it an incorrect choice. Tiring the child with quiet activities (Choice B) is incorrect as it may stimulate rather than calm the child. Encouraging visitation by friends (Choice D) can lead to increased excitement, hindering the child's ability to fall asleep instead of promoting a restful environment.
4. Immediately after delivery, the nurse assesses the woman's uterine fundus. At what location does the nurse expect to be able to palpate the fundus?
- A. At the level of the umbilicus
- B. Two centimeters above the umbilicus
- C. Midway between the symphysis pubis and umbilicus
- D. In the pelvic cavity
Correct answer: C
Rationale: The correct answer is midway between the symphysis pubis and the umbilicus. Immediately after delivery, the uterus is about the size of a large grapefruit or softball. The fundus can be palpated at this location but then rises to a level just above the umbilicus before sinking to the level of the umbilicus, where it remains for about 24 hours. After 24 hours, the fundus starts descending gradually. By the 10th to 14th day, the fundus is in the pelvic cavity and cannot be palpated abdominally. Choices A and B are incorrect as the fundus is not initially at the level of the umbilicus or 2 centimeters above it. Choice D is also incorrect as the fundus does not remain in the pelvic cavity immediately after delivery.
5.
- 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:
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