NCLEX NCLEX-RN
Health Promotion and Maintenance NCLEX RN Questions
1. A client is preparing to give a stool sample for occult blood. All of the following information is part of teaching for this client EXCEPT:
- A. Avoid eating red meat for 3 days before the test
- B. Collect the stool sample from the toilet after having a bowel movement
- C. The stool does not need to be kept in a container with preservative
- D. A small part of the stool from two areas will be tested using a smear
Correct answer: Collect the stool sample from the toilet after having a bowel movement
Rationale: When preparing to give a stool sample for occult blood testing, clients need specific instructions to ensure accurate results. It is crucial to educate clients to avoid eating red meat for at least 3 days before the test, as the blood in the meat can interfere with the test results. Clients should be informed that the stool does not need to be kept in a container with preservative as it is not required for this type of testing. Additionally, clients should be aware that a small part of the stool from two areas will be tested using a smear. However, collecting the stool sample from the toilet after having a bowel movement is not recommended as it may introduce contaminants and affect the accuracy of the test. Therefore, this information is not part of the correct teaching for the client preparing to give a stool sample for occult blood.
2. While conducting an intake assessment of an adult male at a community mental health clinic, the nurse notes that his affect is flat, he responds to questions with short answers, and he reports problems with sleeping. He reports that his life partner recently died from pneumonia. Which action is most important for the nurse to implement?
- A. Encourage the client to see the clinic's grief counselor.
- B. Determine if the client has a family history of suicide attempts.
- C. Inquire about whether the life partner was suffering from AIDS.
- D. Consult with the health care provider about the client's need for antidepressant medications.
Correct answer: Encourage the client to see the clinic's grief counselor.
Rationale: The client is exhibiting normal grieving behaviors, so referral to a grief counselor is the most important intervention for the nurse to implement. Option B is relevant but is not a high-priority intervention compared to addressing the immediate grief support needs of the client. Option C is irrelevant at this time but might be important when determining the client's risk for contracting the illness. While antidepressant medication might be necessary based on further assessment, grief counseling is a more appropriate initial action as grief is a typical response to the loss of a loved one.
3. You have noticed that the last several patients you have cared for have had questionable blood pressure readings from their arterial lines. When checked against cuff pressures, a discrepancy has been noted, and further investigation has revealed faulty transducers. This is not the first product issue with this company. What positive step could you take to help resolve this situation?
- A. Use the old stock from a previous company
- B. Verify the cuff pressures every hour to ensure accuracy
- C. Notify the risk manager
- D. Form a peer workgroup to evaluate new products
Correct answer: Form a peer workgroup to evaluate new products
Rationale: Forming a peer workgroup to evaluate new products would be an excellent opportunity for collaboration among peers, management, and the purchasing department. When clinicians are engaged to work toward solutions that address patient care issues, they experience more empowerment and control over their work environments. Choice A is incorrect because using old stock from a previous company does not address the root cause of the faulty transducers from the current company. Choice B is incorrect as verifying cuff pressures every hour does not directly address the issue of faulty transducers. Choice C is less effective than forming a peer workgroup as it involves only notifying the risk manager without involving a collaborative effort to resolve the product issue.
4. The nurse transcribes the postoperative prescriptions for a client who returns to the unit following surgery and notes that an antihypertensive medication that was prescribed preoperatively is not listed. Which action should the nurse take?
- A. Consult with the pharmacist about the need to continue the medication.
- B. Administer the antihypertensive medication as prescribed preoperatively.
- C. Withhold the medication until the client is fully alert and vital signs are stable.
- D. Contact the health care provider to renew the prescription for the medication.
Correct answer: Contact the health care provider to renew the prescription for the medication.
Rationale: In this scenario, the nurse has noted that an antihypertensive medication prescribed preoperatively is missing from the postoperative prescriptions. It is essential to renew preoperative medications postoperatively. Therefore, the correct action for the nurse to take is to contact the health care provider to renew the prescription for the antihypertensive medication. Consulting with the pharmacist about the need to continue the medication is not appropriate in this situation as pharmacists do not prescribe or renew medications. Administering the antihypertensive medication as prescribed preoperatively without a current prescription poses a risk to the client's safety. Withholding the medication until the client is fully alert and vital signs are stable does not address the issue of the missing prescription and delays the client's necessary treatment.
5. During the admission assessment of a client with chronic bilateral glaucoma, which statement by the client would the nurse anticipate due to this condition?
- A. “I have constant blurred vision.”
- B. “I can’t see on my left side.”
- C. “I have to turn my head to see my room.”
- D. “I have specks floating in my eyes.”
Correct answer: “I have to turn my head to see my room.”
Rationale: In chronic bilateral glaucoma, peripheral visual field loss occurs due to elevated intraocular pressure, leading to the need to turn the head to compensate for the visual field deficit. This symptom is characteristic of advanced glaucoma. Choice A is incorrect as constant blurred vision is a common symptom but not specific to peripheral vision loss in glaucoma. Choice B is incorrect because specific visual field deficits are more common than complete loss on one side. Choice D is incorrect as seeing floaters (specks floating in the eyes) is associated with other eye conditions like posterior vitreous detachment, not glaucoma.
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