NCLEX-PN
Health Promotion and Maintenance NCLEX Questions
1. What is a chemical reaction between drugs before their administration or absorption known as?
- A. a drug incompatibility
- B. a side effect
- C. an adverse event
- D. an allergic response
Correct answer: a drug incompatibility
Rationale: A chemical reaction between drugs before their administration or absorption is termed a drug incompatibility. This phenomenon commonly occurs when drug solutions are mixed before intravenous administration but can also happen with orally administered drugs. Choices B, C, and D are incorrect because side effects, adverse events, and allergic responses typically occur after the drugs have been administered and absorbed, not before.
2. The nurse is assessing the dental status of an 18-month-old child. How many teeth should the nurse expect to examine?
- A. 6
- B. 8
- C. 12
- D. 16
Correct answer: 12
Rationale: An 18-month-old child should have approximately 12 teeth. Children typically start getting teeth around 6 months of age. By subtracting 6 from the number of months in the child's age, you can calculate the expected number of teeth. For an 18-month-old child, 18 - 6 = 12 teeth. Therefore, the correct answer is 12 teeth. Choices A, B, and D are incorrect because they do not align with the expected dental development in an 18-month-old child.
3. When a nurse-midwife, performing a vaginal examination of a client who suspects that she is pregnant, documents the presence of the Chadwick sign, what does this indicate?
- A. That the cervix appears violet
- B. That cervical softening is present
- C. A positive sign of pregnancy
- D. A thinning of the cervix
Correct answer: That the cervix appears violet
Rationale: The correct interpretation of the Chadwick sign is that the cervix appears violet in color. This sign is a probable sign of pregnancy, characterized by the violet coloration of the cervix due to increased vascularity of the pelvic organs. It is not a definitive positive sign of pregnancy but rather a probable one. Choices B and D are incorrect as cervical softening is known as the Goodell sign, and thinning of the cervix is referred to as the Hegar sign. These signs are also probable signs of pregnancy, but they do not specifically indicate the Chadwick sign.
4. While taking the vital signs of a pregnant client admitted to the labor unit, a nurse notes a temperature of 100.6°F, pulse rate of 100 beats/min, and respirations of 24 breaths/min. What is the most appropriate nursing action based on these findings?
- A. Notify the registered nurse of the findings.
- B. Document the findings in the client’s medical record.
- C. Recheck the vital signs in 1 hour.
- D. Continue collecting subjective and objective data.
Correct answer: Notify the registered nurse of the findings.
Rationale: The correct answer is to notify the registered nurse of the findings. In a pregnant client, the normal temperature range is 98°F to 99.6°F, with a pulse rate of 60 to 90 beats/min and respirations of 12 to 20 breaths/min. A temperature of 100.4°F or higher, along with an increased pulse rate and faster respirations, suggests a possible infection. Immediate notification of the registered nurse is crucial for further evaluation and intervention. While documenting the findings is essential, the priority lies in promptly escalating abnormal vital signs for assessment and management. Rechecking vital signs in 1 hour may delay necessary interventions for a deteriorating condition. Continuing to collect data is relevant but should not delay informing the registered nurse when abnormal vital signs are present.
5. A nurse reviewing the physical assessment findings in a client’s health care record notes documentation that the Phalen test caused numbness and burning. Which disorder does the nurse, on the basis of this finding, conclude that the client has?
- A. Scoliosis
- B. Bone deformity
- C. Heberden nodules
- D. Carpal tunnel syndrome
Correct answer: Carpal tunnel syndrome
Rationale: The Phalen test is specifically used to assess for carpal tunnel syndrome. In this test, the client is asked to hold their hands back to back while flexing the wrists 90 degrees, which can reproduce the numbness and burning sensation experienced by individuals with carpal tunnel syndrome. Scoliosis is a condition characterized by abnormal lateral curvature of the spine, not related to the Phalen test. Bone deformity is a general term that does not specifically relate to the symptoms described. Heberden nodules are bony swellings that occur in osteoarthritis and are not assessed through the Phalen test.
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