NCLEX NCLEX-PN
Health Promotion and Maintenance NCLEX Questions
1. A hepatitis B screen is performed on a pregnant client, and the results indicate the presence of antigens in the client’s blood. On the basis of this finding, the nurse makes which determination?
- A. Hepatitis immune globulin and vaccine will be administered to the newborn infant soon after birth
- B. The results are negative.
- C. The results indicate that the mother does not have hepatitis B
- D. The client needs to receive the hepatitis B series of vaccines.
Correct answer: Hepatitis immune globulin and vaccine will be administered to the newborn infant soon after birth
Rationale: A hepatitis B screen is performed to identify antigens in maternal blood. If antigens are present, it indicates that the mother is a carrier, and the newborn will need to receive hepatitis immune globulin and vaccine soon after birth to prevent transmission. Therefore, choice A is correct. Choices B and C are incorrect because the presence of antigens indicates a positive result, not a negative one or the absence of hepatitis B in the mother. Choice D is incorrect as it suggests the client needs to receive the hepatitis B series of vaccines, which is not the immediate action required when antigens are found in the maternal blood.
2. Which statement about clinical pathways is inaccurate?
- A. They require daily updates.
- B. They illustrate the expected client response to their diagnosis.
- C. The objective is improvement or discharge from the facility.
- D. They are evidence-based.
Correct answer: They require daily updates.
Rationale: The correct answer is that clinical pathways do not necessarily require daily updates. Clinical pathways can be customized to be updated daily, weekly, or at other intervals based on patient needs and facility protocols. Choice A is inaccurate as daily updates are not always mandatory for clinical pathways. Choices B, C, and D are accurate features of clinical pathways: they depict the expected client response to the diagnosis, aim for improvement or discharge, and are grounded in evidence-based practices to ensure optimal care.
3. A nurse assisting with data collection is preparing to auscultate the client’s bowel sounds. The client tells the nurse that he ate lunch just 45 minutes ago. On the basis of this information, which finding does the nurse expect to note?
- A. Gurgling sounds
- B. Hypoactive sounds
- C. Low-pitched sounds
- D. An absence of sounds
Correct answer: Gurgling sounds
Rationale: Bowel sounds are high-pitched, gurgling, cascading sounds that occur irregularly between five and 30 times a minute. In this scenario, since the client ate lunch just 45 minutes ago, the nurse would expect to note gurgling sounds as normal bowel activity. Hypoactive sounds (low-pitched) or an absence of sounds are usually associated with conditions such as abdominal surgery or inflammation of the peritoneum, not with recent food intake. Therefore, the correct answer is gurgling sounds, indicating normal bowel activity following a recent meal.
4. The nurse has just received a change-of-shift report. Which client should the nurse assess first?
- A. A client 2 hours post-lobectomy with 150cc drainage
- B. A client 2 days post-gastrectomy with scant drainage
- C. A client with pneumonia with an oral temperature of 102°F
- D. A client with a fractured hip in Buck’s traction
Correct answer: A client 2 hours post-lobectomy with 150cc drainage
Rationale: The nurse should assess the client 2 hours post-lobectomy with 150cc drainage first because postoperative assessments are crucial during the immediate postoperative period. This client may be at higher risk for complications, such as bleeding or infection, requiring immediate attention. Clients in choices B, C, and D are relatively stable and can be assessed after the immediate postoperative client has been evaluated.
5. A healthcare professional reviewing a client’s record notes documentation that the client has melena. How does the healthcare professional detect the presence of melena?
- A. By checking the client’s urine for blood
- B. By checking the client’s stool for blood
- C. By checking the client’s urine for a decrease in output
- D. By checking the client’s bowel movements for diarrhea
Correct answer: By checking the client’s stool for blood
Rationale: 'Melena' is the term used to describe abnormal black tarry stool that has a distinctive odor and contains digested blood. It usually results from bleeding in the upper gastrointestinal tract and is often a sign of peptic ulcer disease or small bowel disease. The presence of melena is detected by checking the client’s stool for blood. Blood in the client’s urine, decreased urine output, and diarrhea are not associated with the assessment for melena.
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