NCLEX-RN
Health Promotion and Maintenance NCLEX RN Questions
1. Which of the following conditions may cause an increased respiratory rate?
- A. Stooped posture
- B. Narcotic analgesics
- C. Injury to the brain stem
- D. Anemia
Correct answer: D
Rationale: Anemia can lead to an increased respiratory rate. In anemia, there are decreased levels of hemoglobin in red blood cells, which are responsible for carrying oxygen to the body's tissues. To compensate for the reduced oxygen-carrying capacity, the body increases the respiratory rate to bring in more oxygen. Stooped posture (Choice A) is not directly related to an increased respiratory rate. Narcotic analgesics (Choice B) are more likely to cause a decreased respiratory rate due to their central nervous system depressant effects. Injury to the brain stem (Choice C) can affect respiratory function but may not necessarily lead to an increased respiratory rate.
2. Which of the following conditions increases a client's risk of aspiration of stomach contents?
- A. A client is in restraints
- B. A client has a scaphoid abdomen
- C. A client is lying prone
- D. More than one answer is correct
Correct answer: A
Rationale: A client in restraints is at an increased risk of aspiration of stomach contents. When a client is restrained, they may be unable to effectively move or turn their body if they begin to vomit, which can lead to aspiration. This lack of mobility can hinder their ability to protect their airway. On the other hand, a scaphoid abdomen, which is sunken or hollowed, is not a direct risk factor for aspiration. Additionally, lying prone, facing downward, does not necessarily increase the risk of aspiration, as aspiration is more likely when lying supine (facing upward). Therefore, the correct answer is that a client is in restraints.
3. Which of the following interventions is necessary before insertion of an arterial line into the radial artery?
- A. Ensure that the client does not need surgery
- B. Assess the client's grip strength
- C. Perform an Allen test
- D. Check a serum potassium level
Correct answer: C
Rationale: Before inserting an arterial line into the radial artery, it is crucial to perform an Allen test. The Allen test assesses the collateral circulation to the hand by compressing both the radial and ulnar arteries. By occluding the radial artery and releasing the ulnar artery, the nurse can check if the ulnar artery can adequately supply blood to the hand if the radial artery is cannulated. This step ensures that there is adequate circulation to the hand post-insertion of the arterial line. Choice A, ensuring that the client does not need surgery, is not directly related to the insertion of an arterial line and is not a necessary step before the procedure. Choice B, assessing grip strength, is not specific to the vascular status of the hand and does not provide information about the adequacy of collateral circulation. Choice D, checking a serum potassium level, is unrelated to the assessment of radial artery patency and collateral circulation, which are the primary concerns before arterial line insertion.
4. A client with hyperkalemia may exhibit peaked T waves on an electrocardiogram. This manifestation is an early sign of high potassium levels, but the diagnosis should not be based on this aspect alone. Untreated, hyperkalemia can lead to progressively worsening cardiac instability.
- A. A lumbar puncture takes a sample of cerebrospinal fluid from the back, which will be analyzed by the lab.
- B. The physician will insert a needle at the level of L4-L5 in the spinal cord.
- C. The client should lie flat on their back for a specific period following the procedure.
- D. The risks of the procedure include headache, back pain, and infection.
Correct answer: B
Rationale: A lumbar puncture is performed to obtain cerebrospinal fluid for analysis to investigate various conditions affecting the client. During the procedure, the client is typically positioned on their side or sitting leaning over a table with their back rounded. The physician inserts a needle into the back around the L4-L5 vertebrae to collect the sample. Option A is incorrect because a lumbar puncture does not draw blood but instead collects cerebrospinal fluid. Option C is incorrect as the client should not necessarily lie flat for 24 hours post-procedure. Option D is incorrect as the common risks of a lumbar puncture include headache, back pain, and potential infection, not nausea, rash, or hypotension.
5. A nurse is assessing a client's pulse oximetry on the surgical unit. As part of routine interventions, the nurse turns off the exam light over the client's bed. Which of the following best describes the rationale for this intervention?
- A. External light sources may cause falsely high oximetry values
- B. A bright light in the client's face may cause a low pulse oximetry
- C. External light sources may cause falsely low oximetry values
- D. The client needs a dark and quiet room to recover and maintain proper oxygenation
Correct answer: A
Rationale: When assessing a client's pulse oximetry values, the nurse should turn off any extra environmental lights that are unnecessary, including exam lights or over-bed lights. External light sources may cause falsely high oximetry values when the extra light interferes with the sensor of the oximeter, leading to inaccurate readings. Choice B is incorrect because a bright light in the client's face would not directly affect the pulse oximetry values. Choice C is incorrect as external light sources typically cause falsely high, not low, oximetry values. Choice D is incorrect as the primary reason for turning off the light is to prevent falsely high readings, not solely for the client's comfort.
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