a nurse is preparing to measure a clients calf circumference the nurse performs this procedure by performing which action

NCLEX-PN

Health Promotion and Maintenance NCLEX PN Questions

1. A nurse is preparing to measure a client's calf circumference. The nurse performs this procedure by performing which action?

A. Placing a tape measure around the widest point of the lower leg
B. Measuring 2 inches above the knee and placing the tape measure around the client's leg at this point
C. Measuring 2 inches above the ankle and placing the tape measure around the client's leg at this point
D. Measuring 2 inches below the patella and placing the tape measure around the client's leg at this point

Correct answer: A

Rationale: To measure a client's calf circumference accurately, a nurse should place a non-stretchable tape measure around the widest point of the lower leg. It is crucial to ensure that the tape measure is positioned at the same number of centimeters down from a specific landmark, such as the patella, on both legs for consistency. Placing the tape measure 2 inches above the knee (Option B), 2 inches above the ankle (Option C), or 2 inches below the patella (Option D) would not provide an accurate measurement of the calf circumference. Therefore, these options are incorrect choices.

2. An LPN is reviewing medication lists for several clients recently admitted to the hospital. Which of the following scenarios would be least concerning?

A. A client taking allopurinol for gout states they have been taking black cohosh to help with post-menopausal symptoms.
B. A client has an order for warfarin and states they have been taking Ginkgo biloba to improve their memory.
C. A client taking Lipitor states they have been taking ginseng for an energy boost.
D. A client has a prescription for an SSRI and states they have been taking St. John's wort to also help with their depression.

Correct answer: C

Rationale: The least concerning scenario is when a client taking Lipitor states they have been taking ginseng for an energy boost. While ginseng may cause an increased risk of bleeding, it should not interact with Lipitor. On the other hand, St. John's wort should not be taken with an SSRI as it may cause serotonin syndrome, posing a more serious concern. Black cohosh should not be taken with allopurinol as they can both cause hepatotoxicity, especially in combination. Ginkgo biloba should not be taken with warfarin as it causes an increased risk of bleeding, making it a more concerning scenario compared to the client taking Lipitor and ginseng.

3. What classification of drug is Diltiazem?

A. Calcium-Channel Blocker
B. NSAID
C. ACE Inhibitor
D. Beta-Blocker

Correct answer: A

Rationale: Diltiazem belongs to the class of calcium-channel blockers, not NSAIDs, ACE Inhibitors, or Beta-Blockers. Calcium-channel blockers like Diltiazem are used to treat conditions such as hypertension by relaxing blood vessels and increasing the supply of blood and oxygen to the heart. Therefore, the correct classification for Diltiazem is a Calcium-Channel Blocker. NSAIDs, ACE Inhibitors, and Beta-Blockers belong to different classes of drugs with distinct mechanisms of action and therapeutic uses, making them incorrect choices for Diltiazem.

4. At what age are yearly mammograms recommended to start?

A. Yearly mammograms are recommended starting at age 25.
B. Yearly mammograms are recommended starting at age 40.
C. Yearly mammograms are not necessary unless there is a family history of breast cancer.
D. Yearly mammograms are recommended starting at age 20 and continuing until menopause begins.

Correct answer: B

Rationale: The correct answer is B. The American Cancer Society recommends yearly mammograms starting at age 40 and continuing for as long as a woman is in good health. Clinical breast examination should be done about every 3 years for women in their 20s and 30s and every year for women age 40 and older. Women should know how their breasts normally look and feel and report any breast change promptly to the healthcare provider. Breast self-examination should be done monthly starting when a woman is in her 20s. Choice A is incorrect as mammograms are not recommended to start at age 25. Choice C is incorrect as yearly mammograms are still recommended even without a family history of breast cancer. Choice D is incorrect as the recommended age for starting yearly mammograms is 40, not 20.

5. A sexually active adolescent asks the school nurse about the use of latex condoms and the reduction of the risk of sexually transmitted infections (STIs). The nurse provides which information to the adolescent?

A. Using a latex condom is a good method for reducing the risk of sexually transmitted infections (STIs).
B. The only way to reduce the risk of transmission of STIs is abstinence.
C. A spermicide needs to be used along with a condom to prevent transmission of STIs.
D. Using a latex condom can reduce the risk of transmission of STIs.

Correct answer: D

Rationale: The correct answer is that using a condom during intercourse can reduce the risk of STI transmission. Abstinence is a way to prevent STIs, but not the only way. Using a spermicide along with a condom can help prevent pregnancy, not STIs. While condoms may fail to prevent pregnancy, they are effective in reducing the risk of STI transmission. Therefore, using a latex condom for pregnancy prevention is not directly related to preventing the transmission of STIs.