a nurse sees documentation in the clients record indicating that the health care provider has noted the presence of adventitious breath sounds the nur
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Nursing Elites

NCLEX-PN

Health Promotion and Maintenance NCLEX PN Questions

1. A nurse sees documentation in the client's record indicating that the health care provider has noted the presence of adventitious breath sounds. The nurse knows that these types of sounds have which aspect?

Correct answer: D

Rationale: Adventitious breath sounds are abnormal sounds that are not normally heard in the lungs. These sounds are added sounds superimposed on the breath sounds. They are caused by air colliding with secretions in the tracheobronchial passageways or when previously deflated airways pop open. Hollow sounds heard over the trachea and larynx are normal bronchial (tracheal) breath sounds, not adventitious. Rustling sounds heard over the peripheral lung fields are normal vesicular breath sounds, not adventitious. Therefore, the correct answer is that adventitious breath sounds are abnormal sounds that should not be heard in the lungs.

2. The nurse is caring for a female client who has recently been diagnosed with cancer and will soon begin chemotherapy. Which of these statements would require additional follow-up and education?

Correct answer: C

Rationale: This client is at risk for altered body image due to chemotherapy-induced hair loss. A wig can assist in coping with this change. It is advisable for the client to shop for a wig before hair loss occurs to better match color and style. Waiting until all hair falls out may lead to stress and limited options in finding a suitable wig. Choices A, B, and D are accurate. Understanding the timing of susceptibility to infection, maintaining oral health before chemotherapy, and staying hydrated are important aspects of care during chemotherapy. Therefore, the statement 'I should wait until all my hair falls out to purchase a wig' requires additional follow-up and education.

3. Before administering the hepatitis B vaccine to a newborn infant, what should the nurse do?

Correct answer: D

Rationale: Before administering the hepatitis B vaccine to a newborn infant, the nurse must obtain parental consent. Hepatitis B vaccine is typically given at birth, 1 month, and 6 months of age. Checking the infant for jaundice, checking the temperature, and requesting a hepatitis blood screen are unnecessary in this context. Parental consent is crucial for any medical intervention involving minors.

4. When examining the abdomen, a nurse auscultates before palpating and percussing the abdomen. The nurse performs the assessment in this manner for which reason?

Correct answer: B

Rationale: When performing an abdominal assessment, the nurse auscultates the abdomen after inspection. Auscultation is done before palpation and percussion because these assessment techniques can increase peristalsis, which would yield a false interpretation of bowel sounds. This sequence helps prevent false interpretations of bowel sounds due to increased peristalsis caused by palpation and percussion. Options A, C, and D provide incorrect reasons for auscultating the abdomen before palpating and percussing it.

5. What is the therapeutic range for carbamazepine (Tegretol)?

Correct answer: B

Rationale: The therapeutic range for carbamazepine (Tegretol) is 4-10 mcg/mL. This range is established based on the optimal balance between effectiveness and safety. Choices A, C, and D are outside the therapeutic range for carbamazepine, which could lead to suboptimal treatment outcomes or increased risk of toxicity. Choice B (4-10 mcg/mL) is the correct range recommended for therapeutic efficacy while minimizing adverse effects.

Similar Questions

A nurse is preparing to assist the healthcare provider in performing an internal gynecological examination of a client. In which position does the nurse place the client for this examination?
Which of the following statements, if made by the parents of a newborn, does not indicate a need for further teaching about cord care?
A nurse is assisting with data collection regarding skin and peripheral vascular findings on a client in later adulthood. Which observation would the nurse expect to note as an age-related finding?
A nurse is preparing to listen to the apical heart rate in the area of the mitral valve in an adult client. The nurse should place the stethoscope on which part of the client's chest?
While reviewing a client's health care record, a nurse notes documentation of the presence of borborygmus on abdominal assessment. Which finding does the nurse expect to note when auscultating the client's bowel sounds?

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