NCLEX-PN
Health Promotion and Maintenance NCLEX PN Questions
1. When assessing a client with deep pitting edema, with the indentation remaining for a short time and visible leg swelling, how should a nurse document this finding?
- A. 1+ edema
- B. 2+ edema
- C. 3+ edema
- D. 4+ edema
Correct answer: C
Rationale: The correct answer is 3+ edema. When assessing for edema, the nurse presses thumbs against the ankle malleolus or the tibia. If the skin retains an indentation, it indicates pitting edema. The grading scale for pitting edema includes: 1+ for mild pitting with slight indentation and no perceptible leg swelling, 2+ for moderate pitting where the indentation subsides rapidly, 3+ for deep pitting with an indentation remaining briefly and visible leg swelling, and 4+ for very deep pitting with a long-lasting indentation and significant leg swelling. Choices A, B, and D do not accurately represent the severity of the edema described in the scenario.
2. 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.
3. During a routine office visit, which of the following developmental milestones should the nurse screen for in a 6-month-old child?
- A. standing while holding something
- B. rolling over
- C. sitting up
- D. creeping
Correct answer: B
Rationale: The correct developmental milestone for a 6-month-old child that should be screened during a routine office visit is rolling over. At this age, infants typically start rolling over from their stomach to their back and vice versa. Sitting up usually occurs between 7 and 8 months, creeping between 9 and 10 months, and standing while holding something between 8 and 10 months. Therefore, choices A, C, and D are developmentally appropriate but not typically expected at 6 months of age.
4. The LPN is caring for a 9-month-old infant. Which of these behaviors exhibited by the child warrants further investigation?
- A. She prefers crawling over walking and makes no attempt to walk.
- B. She seems distressed by new adults.
- C. She does not respond to her own name.
- D. She only babbles "mama"? and "dada."?
Correct answer: C
Rationale: The correct answer is that the child does not respond to her own name. By 9 months, children should be babbling simple words, crawling, and responding to their name. Not responding to one's name can be an early indicator of a potential developmental delay, warranting further investigation. Preferring crawling over walking, being distressed by new adults, and babbling 'mama' and 'dada' are typical behaviors for a 9-month-old and do not necessarily require immediate concern.
5. During the examination of a client's throat, a nurse touches the posterior wall with a tongue blade and elicits the gag reflex. The nurse documents normal function of which cranial nerves?
- A. Cranial nerves V and VI
- B. Cranial nerves XII and VIII
- C. Cranial nerves XII and VIII
- D. Cranial nerves IX and X
Correct answer: D
Rationale: The correct answer is cranial nerves IX (glossopharyngeal nerve) and X (vagus nerve). When the nurse touches the posterior pharyngeal wall with a tongue blade and elicits the gag reflex, it indicates normal function of these nerves. Cranial nerves V (trigeminal nerve) and VI (abducens nerve) are not directly responsible for the gag reflex. Cranial nerves XII (hypoglossal nerve) and VIII (vestibulocochlear nerve) are not directly involved in eliciting the gag reflex. Testing cranial nerve I involves smell function, and cranial nerve II is related to eye examinations, making them irrelevant in this scenario.
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