NCLEX-PN
Health Promotion and Maintenance NCLEX PN Questions
1. A nurse is preparing to listen to the apical heart rate in the area of the mitral valve in an adult client. The nurse should place the stethoscope on which part of the client’s chest?
- A. Second left interspace
- B. Second right interspace
- C. Left lower sternal border
- D. Fifth left interspace at the midclavicular line
Correct answer: Fifth left interspace at the midclavicular line
Rationale: The correct placement for auscultating the apical heart rate in the area of the mitral valve is the fifth left interspace at the midclavicular line. Placing the stethoscope in the second left interspace would be to listen to the pulmonic valve, the second right interspace is for the aortic valve, and the left lower sternal border is for the tricuspid valve.
2. A healthcare professional is using an otoscope to inspect the ears of an adult client. Which action does the professional take before inserting the otoscope?
- A. Pulling the pinna up and back
- B. Pulling the pinna down and forward
- C. Tipping the client’s head down and toward the examiner
- D. Tipping the client’s head down and away from the examiner
Correct answer: Pulling the pinna up and back
Rationale: In an adult client, the healthcare professional should pull the pinna up and back before inserting the otoscope. This action helps straighten the S shape of the ear canal, making it easier to insert the otoscope directly and comfortably. Tipping the client’s head down and toward or away from the examiner is not the correct action when using an otoscope in an adult. Pulling the pinna down and forward is typically done when examining an infant or a child younger than 3 years old to straighten their ear canal for better visualization.
3. A healthcare provider is assisting with data collection on a client for the major risk factors associated with coronary artery disease (CAD). Which modifiable risk factor does the healthcare provider obtain data on from the client?
- A. Age
- B. Ethnicity
- C. Hypertension
- D. Genetic inheritance
Correct answer: Hypertension
Rationale: The correct answer is 'Hypertension.' Risk factors for CAD are categorized as modifiable and unmodifiable. Unmodifiable risk factors include age, sex, ethnicity, genetic predisposition, and family history of heart disease. Modifiable risk factors include increased concentrations of serum lipids, hypertension, cigarette smoking, obesity, and level of physical activity. In this case, hypertension is a modifiable risk factor that the healthcare provider would obtain data on. Choices A, B, and D are incorrect because age, ethnicity, and genetic inheritance are unmodifiable risk factors for CAD, not modifiable ones.
4. Which reported symptom(s) would indicate a client with Addison’s disease has received too much fludrocortisone (Florinef) replacement?
- A. Oily skin and hair
- B. Weight gain of 6 pounds in one week
- C. Loss of muscle mass in arms and legs
- D. Increased blood glucose level
Correct answer: Weight gain of 6 pounds in one week
Rationale: Fludrocortisone replacement in Addison's disease involves mimicking the action of aldosterone, a mineralocorticoid that causes the retention of sodium and water. Excessive retention of sodium and water can lead to weight gain. Therefore, a sudden increase in weight, especially a significant amount like 6 pounds in one week, can indicate an overdose of fludrocortisone. Choices A, C, and D are incorrect because oily skin and hair, loss of muscle mass, and increased blood glucose levels are not typically associated with excessive fludrocortisone replacement.
5. Which of the following actions should the LPN perform for a client with an active digoxin IV order? Select all that apply.
- A. Monitor ECG rhythm throughout administration.
- B. Administer the medication over at least 5 minutes.
- C. Monitor respirations during administration.
- D. Monitor the client’s pulse for 1 minute prior to administration.
Correct answer: A, D
Rationale: The correct actions for the LPN to perform for a client with an active digoxin IV order are to monitor ECG rhythm throughout administration and monitor the client’s pulse for 1 minute prior to administration. These actions are crucial as digoxin affects the heart's electrical activity, and it should not be administered if the client's pulse is less than 60 bpm. Monitoring respirations and blood pressure are not directly associated with digoxin administration. Administering IV medications is typically outside the LPN's scope of practice.
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