NCLEX NCLEX-PN
Health Promotion and Maintenance NCLEX Questions
1. When planning for the physical assessment of the woman, the nurse ensures that which occurs?
- A. The woman is examined by a female health care provider.
- B. The woman's husband remains in the examining room at all times.
- C. The woman is examined without any other people in the examining room.
- D. Written permission is obtained from the woman to obtain subjective health data.
Correct answer: The woman is examined by a female health care provider.
Rationale: In many cultures, including Muslim, Hindu, and Latino, modesty is important, and exposure of a woman’s genitals to men is considered demeaning. To respect the patient's cultural beliefs and modesty, it is best for a female health care provider to perform the examination. This practice helps to ensure the patient's comfort and adherence to cultural norms. Having the woman examined without any other people in the room (Choice C) may not address the cultural sensitivity required for this situation. Having the woman's husband remain in the examining room at all times (Choice B) may not align with the patient's cultural preferences and may cause discomfort. Written permission from the woman to obtain subjective health data (Choice D) is not directly related to ensuring a culturally sensitive physical assessment in this context.
2. During the work phase of the nurse-client relationship, the client says to her primary nurse, “You think that I could walk if I wanted to, don’t you?” What is the best response by the nurse?
- A. “Yes, if you really wanted to, you could.”
- B. “Tell me why you’re concerned about what I think.”
- C. “Do you think you could walk if you wanted to?”
- D. “I think you’re unable to walk now, whatever the cause.”
Correct answer: “I think you’re unable to walk now, whatever the cause.”
Rationale: This response answers the question honestly and nonjudgmentally and helps to preserve the client’s self-esteem. The nurse acknowledges the client's current inability to walk without attributing it to the client's desire. Choice A provides a positive but unrealistic statement that may diminish the client’s self-esteem by implying a lack of effort. Choice B deflects the client's question and does not address the underlying concern. Choice C may increase the client’s anxiety by suggesting unresolved psychological conflicts related to walking.
3. The LPN is about to give 100 mg Lopressor (metoprolol) to a client. Before administering the drug, they take the patient’s vitals, which are as follows: Pulse: 58 Blood Pressure: 90/62 Respirations: 18/minute What action should the LPN take?
- A. Give the client half the prescribed dose and report the findings to the RN on duty.
- B. Give the client double the dose and report the findings to the RN on duty.
- C. Administer the drug and report the findings to the RN on duty.
- D. Hold the drug and report the findings to the RN on duty.
Correct answer: Hold the drug and report the findings to the RN on duty.
Rationale: Lopressor is given to treat hypertension, and a pulse of 58 and a blood pressure of 90/62 are considered low. To prevent the client from bottoming out, the drug should be held, and the findings reported to the RN, who should consult with the attending physician. LPNs should never adjust client dosing, as that is outside of their scope of practice. It is crucial to follow facility guidelines, which often recommend holding blood pressure medication at 60 bpm and a systolic pressure of 90 or less. By holding the drug and notifying the RN, the LPN ensures the client's safety and allows for appropriate assessment and decision-making by the healthcare team. Giving half the dose or double the dose without proper authorization can lead to serious complications and is considered unsafe practice.
4. A 22-year-old patient in a mental health lock-down unit under suicide watch appears happy about being discharged. Which of the following is probably happening?
- A. The patient is excited about being around family again.
- B. The patient’s suicide plan has probably progressed.
- C. The patient’s plans for the future have been clarified.
- D. The patient’s mood is improving.
Correct answer: The patient’s suicide plan has probably progressed.
Rationale: In this scenario, it is concerning that a patient under suicide watch is happy about being discharged as it may indicate that the patient's suicide plan has advanced. This change in behavior should be taken seriously as it can signal an increased risk of self-harm. Choices A, C, and D are less likely as the patient's happiness about discharge in this context is more indicative of a worsening situation rather than positive outcomes like being around family, clarifying future plans, or improving mood.
5. A client needs to rapidly achieve a therapeutic plasma drug concentration of a medication. Rather than wait for steady state to be achieved, the physician might order:
- A. a maintenance dose.
- B. a loading dose.
- C. a medication with no first-pass effect.
- D. the medication to be given intravenously.
Correct answer: a loading dose.
Rationale: To rapidly achieve a therapeutic plasma drug concentration, a loading or priming dose is ordered. This dose quickly establishes the desired drug level. It is calculated by multiplying the volume of distribution by the desired plasma drug concentration. A maintenance dose, like choice A, is used to maintain the therapeutic level after the loading dose. Waiting for steady state without a loading dose would take five drug half-lives. Choice C, a medication with no first-pass effect, does not directly address the need for rapid attainment of therapeutic levels. While intravenous administration (choice D) offers excellent bioavailability, a single dose by this route may not achieve the desired therapeutic plasma concentration as rapidly as a loading dose.
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