NCLEX-PN
Health Promotion and Maintenance NCLEX Questions
1. The client provides information to a pregnant client who is experiencing nausea and vomiting about measures to relieve the discomfort. Which statement by the mother indicates the need for further information?
- A. ''I should eat five or six small meals a day rather than three full meals.''
- B. ''I need to be sure not to drink liquids with my meals.''
- C. ''I should keep dry crackers at my bedside and eat them before I get out of bed in the morning.''
- D. ''I need to avoid eating fried or greasy foods.''
Correct answer: B
Rationale: To alleviate nausea and vomiting, the client should avoid drinking liquids with meals. The client should keep dry crackers at her bedside, avoid fried foods, and eat smaller meals. Additionally, the client should eat dry crackers every 2 hours to prevent an empty stomach and avoid spicy foods and foods with strong odors, such as onion and cabbage. The incorrect choices are: A) Eating five or six small meals a day instead of three full meals is a correct recommendation. C) Keeping dry crackers at her bedside and eating them before getting out of bed in the morning is a helpful suggestion. D) Avoiding fried or greasy foods is a valid advice to alleviate nausea and vomiting.
2. What ethical obligations do professional nurses have according to the ANA Code of Ethics for Nurses?
- A. patients.
- B. the nursing profession.
- C. provide high-quality care.
- D. all of the above
Correct answer: D
Rationale: The correct answer is 'all of the above.' According to the ANA Code of Ethics for Nurses, professional nurses have ethical obligations to patients (clients), the nursing profession, and providing high-quality care. These elements are fundamental principles outlined in the code of ethics to guide nurses in their practice. Choice A is correct as nurses prioritize the well-being and care of their patients. Choice B is correct as nurses are expected to uphold the values and integrity of the nursing profession. Choice C is correct as providing high-quality care is a core ethical obligation of nurses. Therefore, all the choices align with the ANA Code of Ethics for Nurses.
3. A client who is experiencing infertility says to the nurse, 'I feel I will be incomplete as a man/woman if I cannot have a child.' Which of the following nursing diagnoses is likely to be appropriate for this client?
- A. Risk for Self-Harm
- B. Body Image Disturbance
- C. Ineffective Role Performance
- D. Powerlessness
Correct answer: B
Rationale: The correct nursing diagnosis for this client is 'Body Image Disturbance.' The client's statement reflects concerns about self-identity and feeling incomplete due to infertility, which aligns with Body Image Disturbance. The statement does not directly indicate a risk for self-harm, so 'Risk for Self-Harm' is not the correct choice. 'Ineffective Role Performance' is not the best option as it does not address the client's primary concern regarding self-image. While 'Powerlessness' could be appropriate if the client expressed feelings of powerlessness related to infertility, it is not the most suitable diagnosis based on the given statement.
4. The LPN is taking care of a client with a documented allergy to Penicillin. After rounds, the LPN notices that the client has an order for Cefazolin. Which of the following actions would be the least appropriate?
- A. The LPN clarifies the severity of the Penicillin allergy.
- B. The LPN discusses the order with the care team prior to administering Cefazolin.
- C. The LPN administers all ordered medications except for the Cefazolin.
- D. The LPN monitors the client after a test dose of Cefazolin is administered.
Correct answer: C
Rationale: The least appropriate action is for the LPN to administer all ordered medications except for the Cefazolin. The LPN should always consider the client's documented allergy to Penicillin seriously. It is crucial to discuss the order with the care team before administering Cefazolin to ensure patient safety. Administering a medication that could potentially cause harm due to a documented allergy is unsafe practice. While monitoring the client after a test dose of Cefazolin is important, it should not precede clarification with the care team regarding the allergy and the appropriateness of the medication. Therefore, withholding the Cefazolin is the most appropriate action in this scenario.
5. A client with Kawasaki disease has bilateral congestion of the conjunctivae, dry cracked lips, a strawberry tongue, and edema of the hands and feet followed by desquamation of fingers and toes. Which of the following nursing measures is most appropriate to meet the expected outcome of positive body image?
- A. administering immune globulin intravenously
- B. assessing the extremities for edema, redness, and desquamation every 8 hours
- C. explaining progression of the disease to the client and their family
- D. assessing heart sounds and rhythm
Correct answer: C
Rationale: Explaining the progression of the disease to the client and their family is the most appropriate nursing measure to promote a positive body image. By educating them about when symptoms are expected to improve and resolve, they can understand that there will be no permanent disruption in physical appearance that could negatively impact body image. While administering immune globulin intravenously may be part of the treatment for Kawasaki disease, it does not directly address body image concerns. Assessing the extremities for edema, redness, and desquamation every 8 hours is important for monitoring the disease but does not directly impact body image. Assessing heart sounds and rhythm is crucial for monitoring cardiac effects of Kawasaki disease but is not directly related to promoting a positive body image.
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