a nurse is taking the vital signs of a woman who delivered a healthy newborn 1 hour ago the nurse notes that the womans radial pulse rate is 55 beatsm
Logo

Nursing Elites

NCLEX-PN

Health Promotion and Maintenance NCLEX Questions

1. After delivering a healthy newborn 1 hour ago, a nurse notes a woman's radial pulse rate is 55 beats/min. What action should the nurse take based on this finding?

Correct answer: C

Rationale: After delivery, bradycardia (pulse rate 50-70 beats/min) may occur, reflecting the large amount of blood returning to the central circulation after delivery of the placenta. The increase in central circulation results in increased stroke volume, allowing a slower heart rate to provide adequate maternal circulation. A pulse rate of 55 beats/min falls within the normal range post-delivery, so there is no need to notify the healthcare provider immediately. It is important for the client to remain on bed rest in the immediate postpartum period to prevent complications. While range-of-motion exercises are beneficial for a client on bed rest, it is not the priority based on the data provided. Therefore, the most appropriate nursing action is to document the finding for accurate record-keeping and monitoring of the client's condition.

2. While assisting with data collection, the client informs the nurse that he is having difficulty swallowing medications and food. The nurse gathers additional subjective data and documents that the client is experiencing which disorder?

Correct answer: D

Rationale: The correct answer is 'Dysphagia.' Dysphagia is the term used to indicate difficulty swallowing, which can occur in disorders of the throat or esophagus. Anorexia refers to a loss of appetite, not difficulty swallowing. Eructation is the medical term for belching, not difficulty swallowing. Pyrosis is heartburn, a burning sensation in the esophagus and stomach caused by the reflux of gastric acid, not difficulty swallowing.

3. Which of the following home-care strategies is most likely to negatively impact the body image of a client with Cushing's syndrome?

Correct answer: C

Rationale: All of the strategies listed are essential components of home care for a client with Cushing's syndrome. However, wearing a medical ID indicating Cushing's syndrome is the correct answer as it can have a negative impact on body image. This choice may constantly remind the client of their condition, potentially affecting their self-image and confidence. On the contrary, providing safety measures to prevent falls (Choice A) would enhance body image by promoting safety and preventing injuries. Taking medications as prescribed (Choice B) is likely to improve body image by managing symptoms effectively. Having regular health assessments (Choice D) demonstrates good self-care and can positively contribute to body image by showing a commitment to maintaining health.

4. Why is Kleinman's Explanatory Model of Health and Illness significant?

Correct answer: C

Rationale: Kleinman's Explanatory Model of Health and Illness is significant because it emphasizes the influence of popular and folk domains on health perceptions. Kleinman distinguishes between disease, representing the biomedical view, and illness, reflecting individual understanding. The model underscores that cultural factors shape the significance of popular and folk influences on health beliefs. Choice A is incorrect as the model focuses on broader cultural influences, not individual family beliefs. Choice B is incorrect as it oversimplifies the model's emphasis on various cultural aspects. Choice D is incorrect as the model's significance lies in its cultural framework rather than an educational base.

5. While a client is on total parenteral nutrition, which of the following values should the nurse monitor closely?

Correct answer: C

Rationale: Glucose should be monitored closely when a client is on total parenteral nutrition due to the high glucose concentration in the solutions. Monitoring glucose levels is crucial to prevent complications such as hyperglycemia or hypoglycemia. Calcium and magnesium are usually monitored to assess electrolyte imbalances, while cholesterol levels are not directly impacted by total parenteral nutrition. Therefore, choices A, B, and D are not the primary values that need close monitoring during total parenteral nutrition.

Similar Questions

The nurse is assessing an 18-month-old. Which of these statements made by the parent or caregiver would require follow-up?
During a routine health screening for a 1-year-old child, what is the most critical topic for the nurse to discuss with the parents?
When a couple experiencing infertility presents for a fertility workup, which of the following procedures should the nurse prepare the couple to have first?
Which of the following substances need to be assessed when completing a family health assessment?
A Mexican American client with epilepsy is being seen at the clinic for an initial examination. The nurse understands which primary purpose of including cultural information in the health assessment?

Access More Features

NCLEX PN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access

NCLEX PN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access

Other Courses