NCLEX NCLEX-PN
Health Promotion and Maintenance NCLEX Questions
1. A nurse suspects that a client has a distended bladder. On percussing the client’s bladder, which finding does the nurse expect to note if the bladder is full?
- A. Dull sounds
- B. Hyperresonance sounds
- C. Hypoactive bowel sounds
- D. An absence of bowel sounds
Correct answer: Dull sounds
Rationale: When percussing a full bladder, the nurse expects to note dull sounds over the symphysis pubis. This is because a full bladder produces a flat or dull sound. Hyperresonance sounds are present with gaseous distention of the abdomen, not a full bladder. Bowel sounds are auscultated, not percussed, so hypoactive bowel sounds or an absence of bowel sounds are unrelated findings when assessing bladder distention.
2. Is head lag expected to be resolved by 4 months of age? Continuing head lag at 6 months of age may indicate?
- A. Dizziness and orthostatic hypotension.
- B. Nausea, vomiting, diarrhea, or constipation, and stomach cramps.
- C. Drowsiness, lethargy, and fatigue.
- D. Neuropathy and tingling in the extremities.
Correct answer: Nausea, vomiting, diarrhea, or constipation, and stomach cramps.
Rationale: Head lag is a developmental milestone that should be resolved by 4 months of age. Continuing head lag at 6 months of age may indicate potential developmental delays or muscle weakness. The correct answer, 'Nausea, vomiting, diarrhea, or constipation, and stomach cramps,' reflects symptoms that could be associated with developmental delays or underlying health conditions. Dizziness and orthostatic hypotension (Choice A) are unlikely to be directly related to head lag. Choices C and D present symptoms that are unrelated to the issue of continued head lag at 6 months of age.
3. How can the nurse best communicate to a client that he or she has been listening?
- A. restating the main feeling or thought the client has expressed
- B. making a judgment about the client’s problem
- C. offering a leading question such as, 'And then what happened?'
- D. saying, 'I understand what you’re saying.'
Correct answer: restating the main feeling or thought the client has expressed
Rationale: The best way for the nurse to communicate to a client that he or she has been listening is by restating the main feeling or thought the client has expressed. Restating helps the client validate the nurse’s understanding of the communication, demonstrating active listening skills. Making judgments about the client's problem, as suggested in Choice B, can hinder effective communication by introducing bias and potential misinterpretation. Offering a leading question like in Choice C is not ideal for confirming understanding; it rather seeks more information. Choice D, simply saying 'I understand what you’re saying,' may not convey active listening as effectively as restating the client's main feelings or thoughts, as it lacks the validation component present in restating.
4. On morning rounds, the nurse finds a somnolent client with a Blood glucose of 89 mg/dL. A sulfonurea and a proton pump inhibitor are scheduled to be administered. What is the nurse’s best action?
- A. Give the proton pump inhibitor and hold the sulfonurea until the client eats
- B. Hold medications and notify the physician
- C. Arouse the client and give some orange juice with sugar packets added
- D. Give the medications as ordered and re-check blood sugar in one hour
Correct answer: Give the proton pump inhibitor and hold the sulfonurea until the client eats
Rationale: The correct action is to give the proton pump inhibitor and hold the sulfonurea until the client eats. Sulfonureas should be held for blood glucose levels below 100 mg/dL until the client has food to prevent hypoglycemia. Giving the proton pump inhibitor is appropriate and does not need to be delayed. Option B is incorrect because holding both medications without taking appropriate action may lead to further complications. Option C is not the best choice as it does not address the need to hold the sulfonurea until the client eats. Option D is incorrect because administering the medications without ensuring the client eats may lead to hypoglycemia.
5. Which of these would be an appropriate meal for a client with Celiac disease?
- A. egg noodles with cream sauce and broccoli, oat cookie, almond milk
- B. turkey sandwich with rye bread, carrots
- C. chicken and rice, apple, and tapioca pudding
- D. granola and dried apricots with cow’s milk
Correct answer: chicken and rice, apple, and tapioca pudding
Rationale: For individuals with Celiac disease, it's crucial to avoid gluten-containing foods. Choice C, which includes chicken, rice, apple, and tapioca pudding, is the most suitable option as all these foods are naturally gluten-free. Rice, fruits, vegetables, meat, dairy, and tapioca are all safe gluten-free options. Oats can be gluten-free if specially labeled, but many are processed on shared equipment with wheat. Granola often contains oats that may have been exposed to gluten. Dried and prepackaged fruits may contain gluten additives. Rye is a wheat derivative, and cream sauces usually contain flour as a base, making choices A and B inappropriate for individuals with Celiac disease.
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