NCLEX-PN
Health Promotion and Maintenance NCLEX PN Questions
1. What is the threshold of dextrose concentrations that can safely be administered through a peripheral IV?
- A. Dextrose concentrations below 20% can be safely administered through a peripheral IV; dextrose concentrations above 20% should not be administered through a peripheral IV.
- B. Dextrose concentrations below 5% can be safely administered through a peripheral IV; dextrose concentrations above 5% should not be administered through a peripheral IV.
- C. Dextrose concentrations below 10% can be safely administered through a peripheral IV; dextrose concentrations above 10% should not be administered through a peripheral IV.
- D. Dextrose concentrations above 5% can be safely administered through a peripheral IV; dextrose concentrations below 5% should not be administered through a peripheral IV.
Correct answer: C
Rationale: Dextrose concentrations below 10% are considered safe for administration through a peripheral IV, as concentrations above this threshold can lead to phlebitis, causing inflammation of the vein. Concentrations above 10% should not be administered through a peripheral IV to prevent vein irritation. Choice A is incorrect because concentrations above 20% are too high for a peripheral IV. Choice B is incorrect as dextrose concentrations below 5% are too low to be effective. Choice D is incorrect because the statement is reversed, suggesting that concentrations above 5% are safe, which is not true.
2. A nurse notes that a client's physical examination record states that the client's eyes moved normally through the six cardinal fields of gaze. The nurse interprets this to mean that which aspect of eye function is normal?
- A. Near vision
- B. Central vision
- C. Peripheral vision
- D. Ocular movements
Correct answer: D
Rationale: The correct answer is 'Ocular movements.' Moving the eyes through the six cardinal fields of gaze evaluates the function of the eye muscles, such as the medial rectus muscle, superior rectus muscle, superior oblique muscle, lateral rectus muscle, inferior rectus muscle, and inferior oblique muscle. Normal movement in these fields indicates proper ocular movements. Near vision is assessed using a handheld vision screener, central vision with a Snellen chart, and peripheral vision through the confrontation test. Therefore, the evaluation of ocular movements through the six cardinal fields of gaze specifically assesses this aspect of eye function. Choices A, B, and C are incorrect as they pertain to different aspects of vision function that are evaluated using distinct assessment methods, not through the six cardinal fields of gaze.
3. A nurse is reviewing the findings of a physical examination documented in a client's record. Which piece of information does the nurse recognize as objective data?
- A. The client is allergic to strawberries
- B. The last menstrual period was 30 days ago
- C. The client takes acetaminophen (Tylenol) for headaches
- D. A 1-2-inch scar is present on the lower right portion of the abdomen
Correct answer: D
Rationale:
4. Which of the following methods of contraception is able to reduce the transmission of HIV and other STDs?
- A. intrauterine device (IUD)
- B. Norplant
- C. oral contraceptives
- D. vaginal sponge
Correct answer: D
Rationale: The correct answer is the vaginal sponge. The vaginal sponge, when used with foam or jelly contraception, acts as a barrier method that can reduce the transmission of HIV and other STDs, in addition to preventing pregnancy. In contrast, IUDs, Norplant, and oral contraceptives are effective in preventing pregnancy but do not provide protection against the transmission of HIV and STDs. IUDs prevent pregnancy by affecting sperm movement and survival, Norplant releases hormones to prevent ovulation, and oral contraceptives work by inhibiting ovulation. However, these methods do not create a physical barrier against HIV and STD transmission. It is important to counsel clients using methods like IUDs, Norplant, and oral contraceptives to also use chemical or barrier contraceptives to lower the risk of HIV or STD transmission.
5. A woman who delivered a healthy newborn 6 hours earlier complains of discomfort at the episiotomy site. Which action by the nurse is the most appropriate?
- A. Administering an intravenous (IV) opioid analgesic
- B. Assisting the woman in taking a warm sitz bath
- C. Applying an ice pack to the perineum
- D. Contacting the registered nurse
Correct answer: C
Rationale: Applying an ice pack to the perineum is the most appropriate action in this scenario. Ice causes vasoconstriction, providing relief by numbing the area and preventing edema. It is typically used within the first 12 to 24 hours after birth. Assisting the woman in taking a warm sitz bath is more suitable after 24 hours as warm water can be soothing. Administering an IV opioid analgesic is excessive; an anesthetic spray is more appropriate for surface discomfort. Contacting the registered nurse is unnecessary as applying an ice pack is within the nurse's scope and can effectively address the discomfort without escalation.
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