NCLEX-PN
Health Promotion and Maintenance NCLEX Questions
1. A multigravida pregnant woman asks the nurse when she will start to feel fetal movements. Around which week of gestation does the nurse tell the mother that fetal movements are first noticed?
- A. 16 weeks
- B. 6 weeks
- C. 8 weeks
- D. 12 weeks
Correct answer: A
Rationale: Fetal movements (quickening) are first noticed by multigravida pregnant women at 16 to 20 weeks of gestation and gradually increase in frequency and strength. This is when the mother typically begins to feel the baby's movements. Choices B, C, and D are incorrect because fetal movements are not felt as early as 6, 8, or 12 weeks of gestation. At 6 weeks, the embryo's movements are not yet strong enough to be felt by the mother. By 8 weeks, the movements are still too subtle to be perceived. At 12 weeks, although fetal movements start, they are usually not strong enough to be felt by the mother.
2. 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
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.
3. A client can receive the Mumps, Measles, Rubella (MMR) vaccine if he or she:
- A. is pregnant.
- B. is immunocompromised.
- C. is allergic to neomycin.
- D. has a cold.
Correct answer: D
Rationale: A client can receive the MMR vaccine if he or she has a cold without a fever since it does not preclude vaccination. Pregnant women and immunocompromised individuals cannot receive the MMR vaccine because the rubella component is a live virus that may cause birth defects and/or disease. Being allergic to neomycin is also a contraindication as per the American Academy of Pediatrics guidelines. Individuals who have experienced anaphylactic reactions to neomycin should not receive the measles vaccine. Therefore, option D 'has a cold' is the correct choice, as the presence of a simple cold does not prevent the client from receiving the MMR vaccine.
4. A Mexican American client with epilepsy is being seen at the clinic for an initial examination. The nurse understands which primary purpose of including cultural information in the health assessment?
- A. Confirm the medical diagnosis.
- B. Make accurate nursing diagnoses.
- C. Identify any hereditary traits related to the epilepsy.
- D. Determine what the client believes has caused the epilepsy.
Correct answer: D
Rationale: The primary purpose for including cultural information in the health assessment is to determine what the client believes has caused the illness. In Mexican American culture, epilepsy is seen as a reflection of physical imbalance. While gathering data on hereditary traits and formulating nursing diagnoses are important, they are not the primary reasons for including cultural information in the health assessment. It is crucial to understand the client's beliefs as they may impact their perceptions of health, treatment adherence, and overall care. It is not the nurse's role to confirm a medical diagnosis, as this is the responsibility of the healthcare provider.
5. The client is being discharged with a prescription for an inhaled glucocorticoid for asthma. Which of the following statements indicates additional education is needed prior to discharge?
- A. "I will hold my breath for 10 seconds after each puff."?
- B. "I will wait five minutes after taking this medication and then gargle water."?
- C. "I will wait at least one minute between each puff."?
- D. "I will take this medication daily even if I am not having symptoms."?
Correct answer: B
Rationale: The correct answer is, 'I will wait five minutes after taking this medication and then gargle water.' After using an inhaled glucocorticoid, it is essential to wait for 5 minutes and then gargle water to remove any residue from the mouth, which can reduce the risk of developing thrush, a fungal infection. Choice A is correct as holding the breath for 10 seconds after each puff helps the medication reach deep into the lungs. Choice C is also correct as waiting at least one minute between puffs ensures proper delivery of the medication. Choice D is incorrect because it is important to take the medication daily as prescribed to control asthma symptoms, even if the person is not experiencing any at that moment.
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