NCLEX-PN
Health Promotion and Maintenance NCLEX PN Questions
1. The client has an order for an IV piggyback of Ceftriaxone 750mg in 50mL D5W to run over 30 minutes. What is the appropriate drip rate?
- A. 100 mL/hr
- B. 150 mL/hr
- C. 200 mL/hr
- D. 50 mL/hr
Correct answer: A
Rationale: To calculate the drip rate, you need to convert the time from minutes to hours. The formula is (Volume to be infused / Time for infusion in minutes) x (60 minutes / 1 hour). Substituting the values, (50 mL / 30 min) x (60 min / 1 hr) = 100 mL/hr. Therefore, the appropriate drip rate is 100 mL/hr. Choices B, C, and D are incorrect as they do not match the calculated drip rate. Option A, 100 mL/hr, is the correct drip rate for administering Ceftriaxone 750mg in 50mL D5W over 30 minutes.
2. Which of the following client groups should the nurse recognize as the fastest-growing segment of the homeless population?
- A. single, adult men
- B. single mothers with 2 or 3 children
- C. runaway adolescents
- D. single, adult women
Correct answer: B
Rationale: Single mothers with two or three children are indeed the fastest-growing segment of the homeless population. These families, where the majority of children are under the age of five, make up more than one-third of the homeless population in the United States. While single, adult men have traditionally been the largest group in the homeless population, single mothers with children have been increasing in numbers. Runaway adolescents, although a significant group of homeless children, do not represent the fastest-growing segment of the homeless population. Single, adult women are not specified as the fastest-growing segment.
3. An LPN is tasked with checking the narcotic count on a medical-surgical unit. Which statement by the LPN requires further investigation?
- A. "I need a witness when I waste the leftover narcotics in the client's PCA pump."?
- B. "I am going to check the facility's policy for how to dispose of this controlled substance."?
- C. "I left the narcotics box unlocked after confirming the beginning of shift count was correct."?
- D. "The end of shift narcotics count is incorrect and needs to be reported."?
Correct answer: C
Rationale: The LPN's statement about leaving the narcotics box unlocked after confirming the beginning of shift count was correct requires further investigation. Narcotics should be locked and kept in a secure place during the shift to prevent unauthorized access and ensure patient safety. This statement raises concerns about medication security, which is critical in preventing diversion and ensuring patient safety. The other statements demonstrate appropriate actions: A) The LPN acknowledges the need for a witness when wasting leftover narcotics, ensuring proper documentation and accountability during medication waste. B) Checking the facility's policy for proper disposal of controlled substances shows awareness of regulatory compliance regarding controlled substances. D) Recognizing an incorrect end-of-shift narcotics count and planning to report it reflects the LPN's responsibility in maintaining accurate records and addressing discrepancies, which is essential for medication safety and accountability.
4. A nurse auscultating the fetal heart rate (FHR) of a pregnant client in the first trimester of pregnancy notes that the FHR is 160 beats/min. With this information, what should be the nurse's next action?
- A. Notify the healthcare provider of the finding.
- B. Document the findings.
- C. Tell the client that the FHR is faster than normal but that it is nothing to be concerned about at this time.
- D. Wait 15 minutes and then recheck the FHR.
Correct answer: B
Rationale: An FHR of 160 beats/min in the first trimester of pregnancy is within the normal range, which is generally 120 to 160 beats/min. The appropriate action for the nurse in this situation is to document the findings. There is no need to notify the healthcare provider as this is a normal finding. Informing the client that the FHR is faster than normal may cause unnecessary anxiety, as it falls within the expected range. Waiting to recheck the FHR is not necessary since the rate is already within the normal range.
5. What is most likely to impact the body image of an infant newly diagnosed with Hemophilia?
- A. immobility
- B. altered growth and development
- C. hemarthrosis
- D. altered family processes
Correct answer: D
Rationale: Altered Family Processes play a significant role in impacting the body image of an infant newly diagnosed with Hemophilia. Infants are highly perceptive of their caregivers' responses, and any changes in family dynamics due to the diagnosis can affect the infant's sense of security and trust, influencing their body image and self-perception. Immobility, while a long-term effect of hemophilia, is not an immediate impact on body image. Altered growth and development would not have manifested immediately post-diagnosis. Hemarthrosis, characterized by bleeding into joint spaces, is a hallmark of hemophilia but does not directly influence body image in the immediate aftermath of a new diagnosis.
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