NCLEX-PN
Health Promotion and Maintenance NCLEX PN Questions
1. An adult client undergoes various diagnostic tests to determine the pumping ability of the heart. The nurse notes that the results of these tests indicate that the client's cardiac output is 5 L/min. The nurse makes which conclusion?
- A. The client has a low cardiac output.
- B. The client has a high cardiac output.
- C. The client has a normal cardiac output.
- D. The client will need a blood transfusion.
Correct answer: C
Rationale: A cardiac output of 5 L/min falls within the normal range for a resting adult, which typically ranges between 4 and 6 L/min. Cardiac output is calculated as the stroke volume (volume of blood in each systole) multiplied by the heart rate. Therefore, a cardiac output of 5 L/min is considered normal. Choices A and B are incorrect as they misinterpret the result as either low or high, which is not the case based on the provided information. Choice D is unrelated to the client's cardiac output and thus incorrect.
2. How should a client's neck be positioned for palpation of the thyroid?
- A. flexed toward the side being examined
- B. hyperextended directly backward
- C. flexed away from the side being examined
- D. flexed directly forward
Correct answer: A
Rationale: The correct way to position a client's neck for palpation of the thyroid is to have it flexed toward the side being examined. This positioning helps to better access and palpate the thyroid gland. Option B, hyperextending the neck directly backward, is incorrect as it can make palpation more difficult and uncomfortable for the client. Option C, flexing the neck away from the side being examined, is also incorrect as it may obscure the thyroid gland, making it harder to palpate. Option D, flexing the neck directly forward, is not ideal for thyroid palpation as it does not provide the best access to the gland.
3. When inspecting the ears for cerumen impaction, the nurse checks for which finding?
- A. Redness and swelling of the tympanic membrane
- B. An external auditory canal that is longer than normal
- C. The presence of edema in the external auditory canal
- D. A yellowish or brownish waxy material in the external auditory canal
Correct answer: D
Rationale: When inspecting the ears for cerumen impaction, the nurse should look for a yellowish or brownish waxy material in the external auditory canal. Cerumen, also known as ear wax, is a secretion that can become impacted due to various reasons. It is produced by the vestigial apocrine sweat glands in the external ear canal. Cerumen may partially obscure the eardrum or totally occlude the ear canal. The other options, redness and swelling of the tympanic membrane, an external auditory canal that is longer than normal, and the presence of edema in the external auditory canal, are not indicative findings of cerumen impaction.
4. A nurse assisting with data collection is preparing to auscultate the client's bowel sounds. The client tells the nurse that he ate lunch just 45 minutes ago. On the basis of this information, which finding does the nurse expect to note?
- A. Gurgling sounds
- B. Hypoactive sounds
- C. Low-pitched sounds
- D. An absence of sounds
Correct answer: A
Rationale: Bowel sounds are high-pitched, gurgling, cascading sounds that occur irregularly between five and 30 times a minute. In this scenario, since the client ate lunch just 45 minutes ago, the nurse would expect to note gurgling sounds as normal bowel activity. Hypoactive sounds (low-pitched) or an absence of sounds are usually associated with conditions such as abdominal surgery or inflammation of the peritoneum, not with recent food intake. Therefore, the correct answer is gurgling sounds, indicating normal bowel activity following a recent meal.
5. What is the primary force in sex education in a child's life?
- A. school nurse
- B. peers
- C. parents
- D. media
Correct answer: C
Rationale: Parents are the primary force in sex education in a child's life. Parents play a central role in shaping a child's understanding of sex from an early age. They provide continuous guidance, values, and information about sex and relationships. While the school nurse is involved in formal sex education and counseling within the school setting, parents have the most direct and significant impact on a child's sex education. Peers become more influential during adolescence, but their information may not always be accurate or appropriate. The media also exert significant influence on children's perceptions of sex through various forms of entertainment like movies, TV shows, and video games, but parents remain the primary educators on this subject.
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