NCLEX NCLEX-PN
Health Promotion and Maintenance NCLEX Questions
1. An Rh-negative woman with previous sensitization has delivered an Rh-positive fetus. Which of the following nursing actions should be included in the client’s care plan?
- A. emotional support to help the family cope with feelings of guilt about the infant’s condition
- B. administration of MICRhoGam to the woman within 72 hours of delivery
- C. administration of Rh-immune globulin to the newborn within 1 hour of delivery
- D. lab analysis of maternal Direct Coombs’ test
Correct answer: emotional support to help the family cope with feelings of guilt about the infant’s condition
Rationale: In this scenario, the Rh-negative woman has been sensitized, posing a risk to any Rh-positive fetus she delivers. The most appropriate nursing action is to provide emotional support to help the family cope with the infant's condition. This includes addressing potential outcomes like death or neurological damage. Administering MICRhoGam (Choice B) to a sensitized woman is not recommended; it is only given post-abortion or ectopic pregnancy to prevent sensitization. Rh-immune globulin is not administered to the newborn (Choice C) in this case. Analyzing the maternal Direct Coombs’ test (Choice D) is unnecessary; instead, an Indirect Coombs’ test is used to assess sensitization. Therefore, the correct nursing action is to offer emotional support to the family, acknowledging the challenges they may face.
2. Hearing screening of prematurely born infants is an effective means of identifying disease and is an example of:
- A. Primary prevention.
- B. Secondary prevention.
- C. Tertiary prevention.
- D. Disability prevention.
Correct answer: B
Rationale: The correct answer is B: Secondary prevention. Hearing screening for prematurely born infants falls under secondary prevention, which aims to identify and treat a condition in its early stages to prevent further complications. Primary prevention (choice A) focuses on preventing the disease from occurring, while tertiary prevention (choice C) involves managing complications and preventing disability. Choice D, disability prevention, is not a recognized category of prevention. In this context, the screening helps in early identification of hearing loss, allowing for timely intervention to prevent further impairment or complications, aligning with the principles of secondary prevention.
3. The nurse notes the patient care assistant looking through the personal items of the client with cancer. Which action should be taken by the registered nurse?
- A. Notify the police department for investigation
- B. Report this behavior to the charge nurse
- C. Monitor the situation and document any suspicious activities
- D. Confront the patient care assistant immediately
Correct answer: Report this behavior to the charge nurse
Rationale: The appropriate action for the registered nurse in this scenario is to report the behavior to the charge nurse. This allows for proper investigation and intervention. Inappropriate actions include notifying the police directly without following the chain of command (Choice A), monitoring without immediate action (Choice C), and confronting the assistant without involving a superior (Choice D). By reporting to the charge nurse, the situation is escalated appropriately within the healthcare setting, ensuring the well-being and safety of the client.
4. When a client has a chest drainage system in place, where should the system be placed?
- A. above the level of the client's chest
- B. at the level of the client's shoulders
- C. at the level of the chest
- D. below the level of the chest
Correct answer: below the level of the chest
Rationale: A chest drainage system should be placed below the level of the client’s chest to ensure proper drainage of fluid from the chest. Placing the system above the level of the chest or at the shoulders would not allow gravity to assist in the drainage process, potentially leading to complications such as fluid accumulation. Similarly, placing it at the level of the chest would not create the necessary gravity-dependent flow for effective drainage, which is crucial for the proper functioning of the chest drainage system.
5. What is the most common cause of injury from a house fire?
- A. Explosion
- B. Falls from second-story windows
- C. Thermal damage to skin and body surfaces
- D. Inhalation injury
Correct answer: Inhalation injury
Rationale: Inhalation injury is the most common cause of injury from a house fire. When a fire occurs, the smoke produced contains harmful gases and particles that can be inhaled, leading to serious respiratory issues. This makes inhalation injury the primary concern during a house fire. Choices A, B, and C are less likely to be the primary cause of injury. While explosions may occur in some cases, inhalation of smoke and toxic fumes is generally the most prevalent danger. Falls from windows and thermal damage to the skin are also significant risks but typically occur after inhalation injuries in the sequence of events during a house fire.
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