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. 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.
3. 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.
4. Which of the following conditions may warrant a serum creatinine level?
- A. Rhabdomyolysis
- B. Digitalis toxicity
- C. Glomerulonephritis
- D. All answers are correct
Correct answer: D
Rationale: A serum creatinine level may be warranted in conditions that can affect renal function or cause muscle breakdown. Rhabdomyolysis, characterized by muscle injury and breakdown, can lead to elevated creatinine levels due to the release of creatinine from muscles. Digitalis toxicity can impair renal function, leading to a need for monitoring creatinine levels. Glomerulonephritis, an inflammatory condition affecting the kidney's filtering units, can also impact renal function and require assessment of creatinine levels. Therefore, all the provided conditions may warrant a serum creatinine level to assess renal function and muscle breakdown.
5. A client is preparing to undergo a cystoscopy for stones. Which of the following statements indicates that the client understands the procedure?
- A. I better drink a lot of fluid now because I won't be able to after the test.
- B. I will probably see a little blood when I urinate.
- C. I will be able to go home after 3 days in the hospital.
- D. I won't need any pain medicine; this probably will not hurt.
Correct answer: B
Rationale: The correct answer is, 'I will probably see a little blood when I urinate.' During a cystoscopy, a scope is inserted into the client's bladder to inspect structures or remove objects like stones. This procedure is usually performed under local or general anesthesia. It is common for clients to experience a small amount of blood in their urine (hematuria) or have pink-colored urine after the procedure. The other choices are incorrect because drinking a lot of fluid before the test, staying in the hospital for 3 days, and assuming no pain will be experienced are not accurate statements related to a cystoscopy procedure.
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