NCLEX-RN
Health Promotion and Maintenance NCLEX RN Questions
1. A client is receiving education on cholesterol. Which of the following statements from the client indicates the need for further teaching?
- A. I would like my HDL levels to be over 50.
- B. It is better for me to have high HDL levels and low LDL levels.
- C. It is better for me to have high LDL levels and low HDL levels.
- D. My goal is to get my total cholesterol below 200.
Correct answer: C
Rationale: The correct answer is, 'It is better for me to have high LDL levels and low HDL levels.' This statement indicates a need for further teaching because high LDL levels contribute to atherosclerosis, while high HDL levels can protect against heart disease. The client should understand the importance of lowering LDL levels and increasing HDL levels to maintain good heart health. Choice A is correct as desiring HDL levels over 50 is a positive goal. Choice B is correct as it reflects the ideal scenario of high HDL and low LDL levels. Choice D is correct as a total cholesterol below 200 is a common goal for heart health. Therefore, Choice C is incorrect as it suggests an opposite and unhealthy relationship between LDL and HDL levels.
2. A nurse is assisting a pregnant client who is having an amniocentesis. Which of the following statements by the nurse indicates the correct teaching for this procedure?
- A. I'm going to help you lie lat on your back for this."
- B. Don't worry, I'm sure everything will be all right."
- C. I will need to help you remove your shirt for this procedure."
- D. Now that the procedure is inished, I will put a small bandage over the puncture site."
Correct answer: D
Rationale: An amniocentesis is performed to draw amniotic luid from the sac around the fetus during pregnancy. It may be analyzed for certain disorders or complications associated with pregnancy. Following the procedure, the nurse should wash the client's abdomen and place a small bandage over the puncture site
3. Which of the following is an example of a breach of a client's right to privacy?
- A. A nurse who is not caring for the client reads the client's personal information in the chart
- B. A client is not allowed to keep a copy of their original medical record
- C. A nurse files an incident report about a client that is reviewed with all staff at a meeting
- D. A client's photograph is used without permission for the hospital newsletter
Correct answer: D
Rationale: A breach of a client's right to privacy can occur when their personal information is used or disclosed without their consent. In this scenario, using a client's photograph without permission for the hospital newsletter violates their privacy rights. It is important to respect a client's confidentiality and seek their consent before using their personal information. Choices A, B, and C do not directly relate to breaching a client's right to privacy. Reading a client's personal information in their chart, not allowing a client to keep a copy of their medical record, and filing an incident report about a client do not necessarily violate their privacy rights as long as the information is handled appropriately and within legal and ethical boundaries.
4. Which of the following statements best describes compartment syndrome?
- A. An injury causes pain and tingling that starts in the buttock and travels down the leg.
- B. An injury causes swelling within muscle tissue that leads to anoxia of nerves and muscles.
- C. An injury causes permanent flexion of the interphalangeal joint, resulting in deformity.
- D. An injury causes pain and swelling of the median plantar nerve.
Correct answer: B
Rationale: Compartment syndrome is characterized by swelling and increased pressure within a muscle compartment, leading to decreased blood flow and oxygen supply to nerves and muscles. This can result from various causes, such as trauma or the application of a cast after a fracture. If left untreated, compartment syndrome can lead to tissue necrosis. Choice A is incorrect as pain and tingling starting in the buttock and traveling down the leg are not specific features of compartment syndrome. Choice C is incorrect as permanent flexion of the interphalangeal joint is unrelated to compartment syndrome. Choice D is incorrect as pain and swelling of the median plantar nerve do not describe compartment syndrome.
5. A nurse is providing discharge instructions for a client who had back surgery. All of the following indicate that the client is ready for discharge EXCEPT:
- A. The client still has sutures at the incision site
- B. The client is able to take a shower
- C. The client must still use an ice pack at the wound site
- D. The client has a temperature of 100.8�F
Correct answer: D
Rationale: When determining if a client is ready for discharge after back surgery, it is essential to ensure that there are no signs of complications or emerging issues. A postoperative temperature of 100.8�F may indicate a developing infection, and the client should not be discharged until this is further evaluated by the physician. Choices A, B, and C are indicators that the client is progressing well and ready for discharge, as having sutures, being able to shower, and using an ice pack are typically expected postoperative activities without indicating a need for further hospitalization.
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