NCLEX-PN
Health Promotion and Maintenance NCLEX PN Questions
1. A laboring client is experiencing late decelerations. Which position should she be placed in?
- A. left lateral
- B. lithotomy
- C. semi-Fowler's
- D. right lateral
Correct answer: A
Rationale: The correct answer is the left lateral position. Placing the laboring client in the left lateral position is beneficial because it promotes blood flow to the placenta. Late decelerations indicate potential issues with fetal oxygenation, and changing the position to left lateral can help improve placental perfusion. Choices B, C, and D are incorrect because lithotomy, semi-Fowler's, and right lateral positions do not specifically address the need for improved blood flow to the placenta in cases of late decelerations.
2. A nurse is palpating a client's sinus areas. Which sensation does the nurse expect the client to indicate that he or she is feeling during palpation if the sinuses are normal?
- A. Firm pressure
- B. Pain behind the eyes
- C. Pain during palpation
- D. Pressure producing an acute headache
Correct answer: A
Rationale: The correct answer is A: Firm pressure. When the sinuses are normal, the client is expected to feel firm pressure during palpation. Pain during palpation of the sinuses is indicative of acute sinusitis, not a normal finding. Pain behind the eyes and pressure producing an acute headache are symptoms of acute sinusitis, not sensations felt during sinus palpation in normal sinuses.
3. Which of the following statements, if made by the parents of a newborn, does not indicate a need for further teaching about cord care?
- A. "I should put alcohol on my baby's cord 3-4 times a day."?
- B. "I should put the baby's diaper on so that it covers the cord."?
- C. "I should call the physician if the cord becomes dark."?
- D. "I should wash my hands before and after I take care of the cord."?
Correct answer: A
Rationale: Explanation: Parents should be taught that putting alcohol or other antimicrobials on the cord is no longer recommended for cord care. This can interfere with the natural healing process and may increase the risk of irritation or infection. Washing hands before and after providing cord care is essential to prevent the transfer of pathogens. Placing the baby's diaper below the cord allows it to be exposed to air and promotes drying, reducing the risk of infection. It is normal for the cord to turn dark as it dries, so calling the physician only if the cord becomes red, swollen, or has discharge is appropriate. Therefore, the statement '"I should put alcohol on my baby's cord 3-4 times a day."?' indicates a need for further teaching about cord care.
4. A nurse sees documentation in the client's record indicating that the health care provider has noted the presence of adventitious breath sounds. The nurse knows that these types of sounds have which aspect?
- A. Normally heard in the lungs
- B. Hollow sounds heard over the trachea and larynx
- C. Rustling sounds heard over the peripheral lung fields
- D. Abnormal sounds that should not be heard in the lungs
Correct answer: D
Rationale: Adventitious breath sounds are abnormal sounds that are not normally heard in the lungs. These sounds are added sounds superimposed on the breath sounds. They are caused by air colliding with secretions in the tracheobronchial passageways or when previously deflated airways pop open. Hollow sounds heard over the trachea and larynx are normal bronchial (tracheal) breath sounds, not adventitious. Rustling sounds heard over the peripheral lung fields are normal vesicular breath sounds, not adventitious. Therefore, the correct answer is that adventitious breath sounds are abnormal sounds that should not be heard in the lungs.
5. An adult client tells the clinic nurse that he is susceptible to middle ear infections. About which risk factor related to infection of the ears does the nurse question this client?
- A. Loud music
- B. Use of power tools
- C. Occupational noise
- D. Exposure to cigarette smoke
Correct answer: D
Rationale: The correct answer is 'Exposure to cigarette smoke.' Otitis media (middle ear infection) is associated with various factors like colds, allergies, sore throats, and blockage of the eustachian tubes. Risk factors include exposure to cigarette smoke, youth (as otitis media is usually a childhood disease), congenital abnormalities, immune deficiencies, family history of otitis media, recent upper respiratory infections, and allergies. Choices A, B, and C (Loud music, Use of power tools, and Occupational noise) are more likely to cause hearing loss rather than being direct risk factors for middle ear infections.
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