NCLEX NCLEX-PN
Health Promotion and Maintenance NCLEX PN Questions
1. A 37-year-old female client asks the nurse about contraception options and expresses interest in oral contraception pills. Which of the following statements would indicate that oral contraception is appropriate for this client?
- A. “I quit smoking last year, but I started again recently. Maybe I’ll try to quit later this year.”
- B. “I am very diligent in taking my thyroid medications at the same time every day.”
- C. “I was hospitalized for deep vein thrombosis five years ago.”
- D. “I was recently diagnosed with breast cancer.”
Correct answer: “I was hospitalized for deep vein thrombosis five years ago.”
Rationale: The correct answer is the statement mentioning a history of deep vein thrombosis five years ago. Oral contraceptives are generally not recommended for individuals with a history of deep vein thrombosis due to the increased risk of blood clots. Choice B, about being diligent in taking thyroid medications, does not directly relate to the safety of using oral contraceptives. Choice D, about a recent breast cancer diagnosis, would contraindicate the use of hormonal contraceptives. Choice A, mentioning a recent return to smoking, raises concerns about using hormonal contraceptives due to the increased risk of cardiovascular complications.
2. A client returns to the nursing unit post-thoracotomy with two chest tubes in place connected to a drainage device. The client’s spouse asks the nurse about the reason for having two chest tubes. The nurse’s response is based on the knowledge that the upper chest tube is placed to:
- A. Remove air from the pleural space
- B. Create access for irrigating the chest cavity
- C. Evacuate secretions from the bronchioles and alveoli
- D. Drain blood and fluid from the pleural space
Correct answer: Remove air from the pleural space
Rationale: The correct answer is 'Remove air from the pleural space.' When a client has two chest tubes in place post-thoracotomy, the upper chest tube is typically positioned to remove air from the pleural space. Air rises, so placing the tube at the top allows for efficient removal of air that has accumulated in the pleural cavity. Choice B, creating access for irrigating the chest cavity, is incorrect as chest tubes are not primarily used for irrigation. Choice C, evacuating secretions from the bronchioles and alveoli, is incorrect as chest tubes are not designed for this purpose. Choice D, draining blood and fluid from the pleural space, is also incorrect as the upper chest tube in this scenario is specifically for removing air, not blood or fluid.
3. A client is experiencing chest pain. Which statement made by the client indicates angina rather than a myocardial infarction?
- A. “I became dizzy when I stood up.”
- B. “I was nauseated and began vomiting.”
- C. “The pain started in my chest and stopped after I sat down.”
- D. “The pain began with a migraine and progressed to numbness in my left arm.”
Correct answer: “The pain started in my chest and stopped after I sat down.”
Rationale: The correct answer is: '“The pain started in my chest and stopped after I sat down.” This statement suggests angina rather than a myocardial infarction because angina is typically triggered by exertion or stress and relieved by rest. Nausea and vomiting (Choice B) are more commonly associated with a myocardial infarction. Choices A and D are not typical symptoms of either angina or myocardial infarction.
4. A nurse is working in a pediatric clinic, and a 25-year-old mother comes in with a 4-week-old baby. The mother is stressed out about the loss of sleep, and the baby exhibits signs of colic. Which of the following techniques should the nurse teach the mother?
- A. Distraction of the infant with a red object
- B. Prone positioning techniques
- C. Tapping reflex techniques
- D. Neural warmth techniques
Correct answer: Neural warmth techniques
Rationale: Neural warmth techniques involve the caregiver providing a warm, soothing touch to the baby, which can help to lower the baby’s agitation level and promote relaxation. This technique is beneficial for calming colicky babies. Choices A, B, and C are incorrect because distraction with a red object, prone positioning, and tapping reflex techniques are not effective methods for managing colic in infants. Red object distraction is not a proven technique for soothing colicky babies. Prone positioning is not recommended for infants due to the risk of sudden infant death syndrome (SIDS). Tapping reflex techniques are not recognized as effective interventions for colic.
5. The nurse is caring for a client with cirrhosis of the liver and suspects that the client may be developing hepatic encephalopathy. Which assessment by the nurse suggests that the client is developing this complication?
- A. Asterixis
- B. Hypertension
- C. Kussmaul respirations
- D. Lethargy
Correct answer: Asterixis
Rationale: Asterixis, also known as flapping tremors, is a characteristic sign of hepatic encephalopathy. It is a flapping tremor of the hands when the wrists are extended, indicating neurological impairment. Hypertension and Kussmaul respirations are not directly associated with hepatic encephalopathy. Lethargy is a common symptom but not a specific sign that suggests the development of hepatic encephalopathy.
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