NCLEX NCLEX-PN
Health Promotion and Maintenance NCLEX PN Questions
1. A mother brings her 1-year-old child to the clinic. The child has no record of previous immunizations, and the mother confirms the child has not been immunized. Teaching by the nurse should include which of the following?
- A. Immunizations may be started at any age.
- B. The recommended immunization schedule should be followed.
- C. If a primary series of immunizations is interrupted, it can be continued.
- D. Delaying the start of vaccines does not increase the risk of reaction.
Correct answer: Immunizations may be started at any age.
Rationale: The correct answer is 'Immunizations may be started at any age.' While there is a recommended immunization schedule, immunizations can be initiated at any age. It is essential to emphasize the flexibility in starting immunizations. The statement 'The recommended immunization schedule should be followed' is too rigid; while recommended, there is flexibility in initiation. Choice C is correct as an interrupted series can be continued without restarting. The statement 'Delaying the start of vaccines does not increase the risk of reaction' is correct. Delaying does not increase the risk of reaction; in fact, it is important to start immunizations to protect the child and the community.
2. What is a common characteristic of individuals who become batterers?
- A. Grew up in a loving, secure home.
- B. Was an only child.
- C. Was physically or psychologically abused.
- D. Admits they have a problem with anger.
Correct answer: Was physically or psychologically abused.
Rationale: The correct answer is 'Was physically or psychologically abused.' Research indicates that many individuals who become batterers have a history of being abused themselves. This cycle of abuse can influence their behavior as adults. Choice A is incorrect because growing up in a loving home does not necessarily prevent someone from becoming a batterer. Choice B is incorrect as being an only child is not a determining factor in becoming a batterer. Choice D is incorrect because while admitting to anger issues is a positive step, it is not a common characteristic of individuals who become batterers.
3. During surgery, it is found that a client with adenocarcinoma of the rectum has positive peritoneal lymph nodes. What is the next most likely site of metastasis?
- A. brain
- B. bone
- C. liver
- D. mediastinum
Correct answer: C
Rationale: In cases of adenocarcinoma of the rectum with positive peritoneal lymph nodes, the most likely site of metastasis is the liver. Colon tumors commonly spread through the lymphatics and portal vein to the liver. While metastasis to the brain, bone, or mediastinum is possible, the liver is typically the first to be affected due to the anatomical pathways involved in colorectal cancer metastasis. Therefore, the correct answer is the liver. Metastasis to the brain, bone, or mediastinum would be less likely at this stage of colorectal cancer progression.
4. A health care provider writes a medication prescription in a client’s record. While transcribing the prescription, the nurse notes that the prescribed dose is three times higher than the recommended dose. The nurse calls the health care provider, who states that this is the dose that the client takes at home and that it is acceptable for this client’s condition. What is the appropriate action for the nurse to take?
- A. Verifying the prescribed dose with the client before administering the medication
- B. Contacting the nursing supervisor
- C. Asking the nurse assigned to care for the client to administer the medication
- D. Continuing to transcribe the prescription
Correct answer: Contacting the nursing supervisor
Rationale: In this scenario, the nurse has identified a significant discrepancy between the prescribed dose and the recommended dose. While the health care provider has justified the higher dose based on the client's home regimen, the nurse's primary responsibility is to ensure patient safety. If a nurse has concerns about a prescription being incorrect or potentially harmful, they should seek further clarification from the health care provider. Since the nurse still believes the dose is inappropriate after discussing with the health care provider, the next appropriate action is to contact the nursing supervisor. Continuing to transcribe the prescription without addressing the concern could jeopardize the client's safety. Asking another nurse to administer the medication without proper resolution of the dosage concern would also pose a risk to the client. While verifying the prescribed dose with the client is important, in this situation, the nurse should first escalate the issue to the nursing supervisor to ensure appropriate actions are taken.
5. Assisting with data collection, a nurse notes tenderness while lightly palpating a client’s right lower quadrant of the abdomen. The nurse determines that this finding is most likely associated with which anatomic structure?
- A. Liver
- B. Spleen
- C. Pancreas
- D. Appendix
Correct answer: D: Appendix
Rationale: The correct answer is the Appendix. Tenderness in the right lower quadrant of the abdomen is a classic sign of appendicitis, which is inflammation of the appendix. The appendix is located in the right lower quadrant. The other choices are incorrect. The spleen is located on the posterolateral wall of the abdominal cavity under the diaphragm. The pancreas is located behind the stomach. The liver fills most of the right upper quadrant and extends to the left midclavicular line.
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