a nurse assisting with data collection is monitoring the client for costovertebral angle tenderness when the nurse percusses the area the client compl a nurse assisting with data collection is monitoring the client for costovertebral angle tenderness when the nurse percusses the area the client compl
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Nursing Elites

NCLEX NCLEX-PN

Health Promotion and Maintenance NCLEX PN Questions

1. While assessing for costovertebral angle tenderness, a nurse percusses the area, and the client complains of sharp pain. The nurse interprets this finding as most indicative of which disorder?

Correct answer: D: Kidney inflammation

Rationale: When assessing for costovertebral angle tenderness, sharp pain on percussion of the area indicates inflammation of the kidney or paranephric area. The correct technique involves placing one hand over the 12th rib, at the costovertebral angle, and thumping that hand with the ulnar edge of the other fist. The client normally feels a thud and should not experience pain. Ovarian infection, liver enlargement, or spleen enlargement are not associated with the costovertebral angle tenderness. Therefore, the correct answer is kidney inflammation.

2. After assigning tasks, what is the nurse’s primary responsibility?

Correct answer: Following up with each staff member regarding the performance of the task and the outcomes related to implementation of the task

Rationale: The nurse's primary responsibility after assigning tasks is to follow up with each staff member regarding the task's performance and outcomes. This ensures accountability and quality care delivery. Allowing staff members to make judgments independently can compromise patient safety if they lack the necessary knowledge or experience. While documenting task completion is important, it should follow the follow-up to assess outcomes. Assigning incomplete tasks to the next shift is not ideal as it may result in unmet patient needs and increased workload for the next shift.

3. When a client informs the nurse that he is experiencing hypoglycemia, the nurse provides immediate intervention by offering:

Correct answer: 2–3 teaspoons of honey.

Rationale: The correct answer is 2–3 teaspoons of honey. In the case of hypoglycemia, the usual recommendation for treatment is 10–15 grams of fast-acting simple carbohydrate orally if the client is conscious and able to swallow. This can be achieved by providing 2–3 teaspoons of honey. While commercially prepared glucose tablets or 4–6 ounces of fruit juice are also suitable choices, adding sugar to unsweetened juice is unnecessary as the fruit sugar in juice contains enough simple carbohydrate to raise blood glucose levels. Adding sugar could lead to a sharp and prolonged increase in blood sugar levels. Two hard candies may not provide the recommended 10–15 grams of fast-acting carbohydrate needed for quick elevation of blood glucose levels in cases of hypoglycemia.

4. Intramuscular (IM) phytonadione (vitamin K) 0.5 mg is prescribed for a newborn. After the medication is prepared, in which anatomic site does the nurse administer it?

Correct answer: Vastus lateralis muscle

Rationale: Vitamin K is administered to newborn infants to help prevent hemorrhagic disease. The best site for intramuscular injection in infants is the vastus lateralis muscle. This site is preferred due to its location away from the sciatic nerve, femoral artery, and vein, reducing the risk of complications. The rectus femoris muscle may be used if necessary; however, it is less favorable than the vastus lateralis due to its proximity to vital structures, making injections there more hazardous. The deltoid muscle is not typically used for IM injections in newborns. The gluteal muscles should be avoided until the child has been walking for at least a year, as they are poorly developed and close to the sciatic nerve.

5. The nurse is caring for a client with cerebral palsy. The nurse should provide frequent rest periods because:

Correct answer: Grimacing and writhing movements decrease with relaxation and rest.

Rationale: Frequent rest periods help to relax tense muscles and preserve energy in clients with cerebral palsy. This can lead to a decrease in grimacing and writhing movements, as relaxation and rest help to alleviate muscle tension. Choices B, C, and D are incorrect because they provide inaccurate information. Hypoactive deep tendon reflexes do not become more active with rest; stretch reflexes are not increased with rest in cerebral palsy patients, and fine motor movements are not necessarily improved solely by rest.

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