a nurse assisting with data collection uses the back of the hand to feel the clients skin on both arms and notes that the skin is warm the nurse makes a nurse assisting with data collection uses the back of the hand to feel the clients skin on both arms and notes that the skin is warm the nurse makes
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Nursing Elites

NCLEX NCLEX-PN

Health Promotion and Maintenance NCLEX PN Questions

1. A nurse assisting with data collection uses the back of the hand to feel the client’s skin on both arms and notes that the skin is warm. The nurse makes which determination?

Correct answer: The skin temperature is normal.

Rationale: To assess skin temperature, the nurse would first note the temperature of their own hands. Then, using the backs of the hands to palpate the client’s skin bilaterally, warmth suggests normal circulatory status if the skin is warm and the temperature is equal bilaterally. The hands and feet may feel slightly cooler in a cool environment. Options A, C, and D are incorrect responses. A warm skin temperature does not indicate a fever, the need for additional fluids, or the need to have the blanket removed.

2. While assisting with data collection of an adult client, a nurse asks the client to identify various odors. In this technique, which cranial nerve is the nurse assessing?

Correct answer: Olfactory

Rationale: The correct answer is 'Olfactory.' The olfactory nerve is responsible for the sense of smell. Assessing this nerve involves testing the client's ability to identify various odors. Loss of smell, head trauma, abnormal mental status, and suspected intracranial lesions are conditions where testing the olfactory nerve is essential. The optic nerve is evaluated for visual acuity and visual fields. The abducens nerve is usually assessed alongside the oculomotor and trochlear nerves, focusing on pupil size, regularity, light reactions, accommodation, and extraocular movements. The hypoglossal nerve is examined by inspecting the tongue, not by assessing the sense of smell.

3. The client returns to the unit from surgery with a blood pressure of 90/50, pulse 132, respirations 30. Which action by the nurse should receive priority?

Correct answer: Contact the physician

Rationale: The priority action for the nurse is to contact the physician immediately due to the client's abnormal vital signs. A blood pressure of 90/50, pulse of 132, and respirations of 30 indicate instability and require prompt medical attention. Continuing to monitor vital signs, as in choice A, may lead to a delay in necessary interventions. Asking the client how they feel, as in choice C, provides subjective data and does not address the urgent need for medical intervention. Involving the LPN, as in choice D, is not appropriate in this critical situation where the client's condition is unstable and requires immediate physician assessment and intervention.

4. The nurse should plan to evaluate the earliest onset of effectiveness of nitroglycerin (Nitrostat) sublingual (SL) within what time frame?

Correct answer: 3 minutes

Rationale: The onset of action for Nitrostat SL is 1 to 3 minutes. Therefore, the nurse should plan to evaluate the earliest onset of effectiveness within 3 minutes after administering the medication. Option A, 15 seconds, is too short of a time frame for the onset of action of Nitrostat. Option C, 5 minutes, is slightly delayed compared to the typical onset time. Option D, 15 minutes, is too long to wait for evaluating the effectiveness of Nitrostat sublingual administration.

5. High uric acid levels can develop in clients who are receiving chemotherapy. This can be caused by

Correct answer: rapid cell catabolism.

Rationale: The correct answer is 'rapid cell catabolism.' Chemotherapy leads to the destruction of cells, resulting in increased uric acid levels due to cell breakdown. Choice A is incorrect because the issue is not with the kidneys' ability to excrete the drug metabolites but rather with the cell breakdown. Choice C is incorrect as the question focuses on chemotherapy and its effects, not prophylactic antibiotics. Choice D is incorrect as the question pertains to the development of high uric acid levels, not altered blood pH from acidic drugs.

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