NCLEX NCLEX-PN
Health Promotion and Maintenance NCLEX PN Questions
1. During a voice test, how should the nurse provide words for the client to repeat?
- A. Spoken in a soft tone of voice by the nurse about 5 feet in front of the client
- B. Whispered by the nurse from the client’s side at a distance of 1 to 2 feet from the ear being tested
- C. Spoken by the nurse from the client’s side in a normal tone of voice about 10 feet from the ear being tested
- D. Whispered at a distance of 20 feet by the nurse while he or she is standing in front of the client
Correct answer: Whispered by the nurse from the client’s side at a distance of 1 to 2 feet from the ear being tested
Rationale: During a voice test, the nurse should whisper words from the client's side at a distance of 1 to 2 feet from the ear being tested. This distance helps prevent transmission around the head and ensures accurate testing of one ear at a time. By standing close to the client and whispering, the nurse prevents lip-reading and compensatory actions by the client. The client with normal hearing should be able to repeat each word correctly. Choices A, C, and D are incorrect. Choice A is wrong as the voice should be whispered, not spoken in a soft tone. Choice C is inaccurate because a distance of 10 feet is too far for precise testing. Choice D is incorrect as whispering from a distance of 20 feet would not effectively test the client's hearing.
2. While preparing a client for a bronchoscopy, a nurse notes that the client is wearing a gold necklace. What should the nurse do to safeguard the client’s necklace?
- A. Ask the client for permission to lock the necklace in the hospital safe
- B. Ask the client to remove the necklace and place it in the top drawer of the bedside table
- C. Ask the client whether the necklace is gold
- D. Ask the client to sign a release to free the hospital of responsibility if the necklace is damaged or lost during the procedure
Correct answer: Ask the client for permission to lock the necklace in the hospital safe
Rationale: When a client has valuables such as jewelry, the nurse should ensure their safekeeping. It is appropriate for the nurse to ask the client for permission to lock the necklace in the hospital safe to prevent loss or damage. This option prioritizes the security of the necklace while allowing the client to make an informed decision. Asking the client to sign a release form does not guarantee the necklace's safety; it only releases the hospital from liability. Placing the necklace in a bedside table drawer does not provide adequate security as it is not as secure as a hospital safe. Inquiring whether the necklace is gold is irrelevant to safeguarding the jewelry during the procedure, as the primary concern is its safekeeping.
3. In an emergency situation where a client is unconscious and requires immediate surgery, what action is necessary with regard to informed consent?
- A. The healthcare team will proceed with the surgery as consent is not needed in emergencies.
- B. The healthcare team will wait until the client's family can be contacted for consent.
- C. The healthcare team will contact the hospital clergy to provide informed consent.
- D. The healthcare team will obtain consent from the client's legal guardian before proceeding.
Correct answer: The healthcare team will proceed with the surgery as consent is not needed in emergencies.
Rationale: In emergency situations where obtaining consent is not possible due to the client's condition, healthcare providers are allowed to perform life-saving procedures without informed consent. It is assumed that the client would want to receive necessary treatment to save their life. Therefore, the correct action is for the healthcare team to proceed with the surgery as consent is not needed. Waiting to contact the client's family for consent can delay life-saving treatment, risking the client's life. Contacting the hospital clergy for consent is unnecessary and can cause further delays. Obtaining consent from the client's legal guardian is not feasible in this critical situation and may lead to a delay in providing essential care.
4. A client is told that his test is positive, but in fact, the client does not have the disease tested for. Which type of false report is this an example of?
- A. positive
- B. false positive
- C. negative
- D. false negative
Correct answer: false positive
Rationale: The correct answer is 'false positive.' A false-positive result occurs when a test result is labeled positive in error, when the actual result is negative. In this scenario, the client received a positive test result incorrectly, as he does not have the disease being tested for. Choice A ('positive') is too vague and does not specify that the result was incorrect. Choice C ('negative') is the opposite of what happened in the scenario. Choice D ('false negative') refers to a situation where a test result is labeled negative incorrectly, which is not the case in this scenario.
5. What is the most effective way to prevent skin breakdown?
- A. assistive devices
- B. repositioning
- C. topical medications
- D. avoiding tape and bandages
Correct answer: repositioning
Rationale: Repositioning is the most effective way to prevent skin breakdown. Repositioning helps relieve pressure on specific areas of the skin, reducing the risk of developing pressure ulcers. While assistive devices (Choice A) may be beneficial in some cases, they are not universally as effective as repositioning. Topical medications (Choice C) are primarily used for treating skin conditions and are not the primary focus for preventing skin breakdown. Avoiding tape and bandages (Choice D) is crucial to prevent skin irritation, but repositioning remains the most effective method to prevent skin breakdown.
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