NCLEX NCLEX-PN
Health Promotion and Maintenance NCLEX PN Questions
1. A nurse assisting with data collection of the peripheral vascular system performs the Allen test. The nurse understands that this test is used to determine the patency of which blood vessel(s)?
- A. Capillaries
- B. Pedal pulses
- C. Femoral arteries
- D. Radial and ulnar arteries
Correct answer: Radial and ulnar arteries
Rationale: The nurse performs the Allen test to determine the patency of the radial and ulnar arteries. During the test, the nurse applies pressure over the client’s ulnar and radial arteries simultaneously. The client is then asked to open and close the hand repeatedly, causing the hand to blanch. Subsequently, the nurse releases pressure from the ulnar artery while compressing the radial artery and checks the color of the extremity distal to the pressure point. If pinkness fails to return within 6 seconds, it indicates that the ulnar artery is insufficient, suggesting that the radial artery should not be used for obtaining a blood specimen. Choice A (Capillaries) is incorrect as the Allen test assesses the patency of larger arteries, not capillaries. Choice B (Pedal pulses) is incorrect as the Allen test specifically evaluates the radial and ulnar arteries, not the pedal pulses in the foot. Choice C (Femoral arteries) is incorrect as the Allen test focuses on the radial and ulnar arteries in the hand, not the femoral arteries in the leg.
2. During the history assessment of an 80-year-old client, which statement made by the client might indicate a possible fluid and electrolyte imbalance?
- A. “My skin is always so dry.”
- B. “I often use a laxative for constipation.”
- C. “I have always liked to drink a lot of iced tea.”
- D. “I sometimes have a problem with dribbling urine.”
Correct answer: “I often use a laxative for constipation.”
Rationale: The correct answer is "I often use a laxative for constipation." Frequent use of laxatives can lead to diarrhea and electrolyte loss, indicating a possible fluid and electrolyte imbalance. Statements A, C, and D are not directly related to fluid and electrolyte imbalance. Statement A about dry skin may suggest dehydration, but it is less specific to electrolyte imbalance than the frequent use of laxatives. Statement C about drinking a lot of iced tea could potentially relate to fluid intake, but it doesn't directly indicate an imbalance. Statement D about dribbling urine is more indicative of a potential urinary issue rather than a fluid and electrolyte imbalance.
3. A nurse suspects that a client has a distended bladder. On percussing the client’s bladder, which finding does the nurse expect to note if the bladder is full?
- A. Dull sounds
- B. Hyperresonance sounds
- C. Hypoactive bowel sounds
- D. An absence of bowel sounds
Correct answer: Dull sounds
Rationale: When percussing a full bladder, the nurse expects to note dull sounds over the symphysis pubis. This is because a full bladder produces a flat or dull sound. Hyperresonance sounds are present with gaseous distention of the abdomen, not a full bladder. Bowel sounds are auscultated, not percussed, so hypoactive bowel sounds or an absence of bowel sounds are unrelated findings when assessing bladder distention.
4. While performing a physical assessment on a 6-month-old infant, the nurse observes head lag. Which of the following nursing actions should the nurse perform first?
- A. Ask the parents to allow the infant to lie on his stomach to promote muscle development.
- B. Notify the physician because a developmental or neurological evaluation is indicated.
- C. Document the findings as abnormal in the nurse’s notes.
- D. Explain to the parents that their child is likely to have developmental delays.
Correct answer: Notify the physician because a developmental or neurological evaluation is indicated.
Rationale: Head lag should be completely resolved by 4 months of age. Continuing head lag at 6 months of age indicates the need for further developmental or neurological evaluation. Laying the infant on his stomach promotes muscle development of the neck and shoulder muscles, but because of the age of this child, a referral should be the first action. The findings are abnormal for a 6-month-old infant. Significant head lag can be seen in infants with Down syndrome and hypoxia, as well as neurological and other metabolic disorders. While some of these disorders might include developmental delays, stating this to the parents without a proper evaluation can cause unnecessary distress. The priority is to identify the cause of the head lag through a medical evaluation before discussing potential outcomes with the parents.
5. What is the best nursing diagnosis for a client with newly diagnosed Diabetes Mellitus?
- A. Impaired Skin Integrity
- B. Knowledge Deficit: New Diabetes Diagnosis
- C. Alteration in Nutrition: More than Body Requirements
- D. Fluid Volume Deficit
Correct answer: Knowledge Deficit: New Diabetes Diagnosis
Rationale: The correct answer is 'Knowledge Deficit: New Diabetes Diagnosis.' Newly diagnosed diabetics require education on their disease, medications, glucose testing, insulin injections, foot care, and sick-day plans. Choices A and D aim to prevent issues that do not currently exist for the client. Choice C, 'Alteration in Nutrition: More than Body Requirements,' is not the priority diagnosis for a newly diagnosed diabetic. While nutritional adjustments may be required for type I or type II diabetes, providing knowledge and education takes precedence at this stage.
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