ask the laboratory to draw another blood sample in 2 hours and repeat the test
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Nursing Elites

NCLEX-PN

Health Promotion and Maintenance NCLEX Questions

1. What is the most appropriate initial action for a newborn infant with low blood glucose?

Correct answer: C

Rationale: The blood glucose level for a newborn infant should remain greater than 40 mg/dL to prevent permanent brain damage. When dealing with low blood glucose in a newborn, the most appropriate initial action is to contact the registered nurse. The nurse will obtain prescriptions regarding feeding the infant with low blood glucose and follow agency policies on feeding infants in such conditions. It is common practice to feed the infant if the glucose level is 40 mg/dL or less. Asking the registered nurse to draw another blood sample in 2 hours and repeating the test is not the most appropriate immediate action, as timely intervention is crucial in this situation. Contacting the healthcare provider may cause unnecessary delays since the registered nurse is usually the first point of contact for immediate actions in this scenario. Documenting the results in the newborn's medical record is essential, but it is not the initial step in managing low blood glucose in a newborn.

2. When caring for pediatric clients, the nurse should pay special attention to the psychosocial development stages credited to whom?

Correct answer: B

Rationale: Erik Erikson is credited with the psychosocial development theory and eight stages. The nurse should consider these stages when caring for pediatric clients to evaluate their development. Jean Piaget is known for cognitive development, Sigmund Freud for psychosexual development, and Robert Peck for aging theory. Therefore, the correct answer is Erik Erikson.

3. The nurse has a client who is being transferred to another floor right around change of shift. Which of the following actions is least appropriate?

Correct answer: C

Rationale: The least appropriate action in this scenario is to ask the new nurse to take care of the transfer without providing a full handoff of care. It is crucial to ensure a safe handoff during the transfer to maintain continuity of care and patient safety. Informing the staff on the other floor of any unresolved issues with the client (Choice A) is important for the client's well-being as it helps in providing comprehensive care. Asking the charge nurse about overtime (Choice B) demonstrates consideration for completing the task effectively, but it should not take precedence over ensuring a proper handoff. Completing the transfer paperwork before the client is transferred (Choice D) is necessary to ensure all documentation is in order, but it should be done in conjunction with providing a thorough handoff of care to the new nurse.

4. What is an appropriate nursing goal for a client at risk for nutritional problems?

Correct answer: B

Rationale: Promoting healthy nutritional practices is an appropriate nursing goal for a client at risk for nutritional problems as it focuses on preventive measures to address the risk of nutritional issues. Choice A is incorrect because providing oxygen is not related to addressing nutritional problems. Choice C is incorrect as it involves treating the consequences rather than preventing nutritional problems. Choice D is incorrect because increasing weight is only suitable if the client is underweight, not as a general preventive measure.

5. A healthcare professional is assisting with data collection of a client with suspected cholecystitis. Which finding does the healthcare professional expect to note if cholecystitis is present?

Correct answer: B

Rationale: The correct answer is B: Murphy sign. The Murphy sign is an indicator of gallbladder disease. It involves the examiner placing fingers under the liver border while the client inhales. If the gallbladder is inflamed, it descends onto the fingers, causing pain. The Homan sign is associated with pain in the calf area upon sharp dorsiflexion of the foot, indicating deep vein thrombosis. The Blumberg sign is the presence of rebound tenderness on palpation of the abdomen, indicating peritoneal irritation. The McBurney sign is indicative of appendicitis, presenting as severe pain and tenderness upon palpation at McBurney's point in the right lower quadrant of the abdomen.

Similar Questions

In the context of diagnostic genetic counseling, which of the following choices is typically not made by clients?
When examining the abdomen, a nurse auscultates before palpating and percussing the abdomen. The nurse performs the assessment in this manner for which reason?
A client who was given a diagnosis of hypertension 3 months ago is at the clinic for a checkup. Which type of database does the nurse use in performing an assessment?
The LPN is caring for a client taking Lipitor (Atorvastatin). Which of these statements would indicate that the client may need reinforced teaching?
The teaching plan for a postpartum client who is about to be discharged should include which of the following instructions?

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