NCLEX NCLEX-PN
Health Promotion and Maintenance NCLEX Questions
1. What is the most appropriate initial action for a newborn infant with low blood glucose?
- A. Ask the registered nurse to draw another blood sample in 2 hours and repeat the test
- B. Contact the healthcare provider
- C. Contact the registered nurse
- D. Document the results in the newborn's medical record
Correct answer: Contact the registered nurse
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. A case management clinical pathway for congestive heart failure might include all of the following except:
- A. physician follow-up appointments with transportation
- B. client education regarding medication use
- C. a nutritional consult for diet review and accommodation
- D. insurance review for reimbursement
Correct answer: insurance review for reimbursement
Rationale: In a case management clinical pathway for congestive heart failure, the focus is on providing medical care and support to the patient. Choices A, B, and C are integral parts of managing congestive heart failure. Physician follow-up appointments with transportation ensure continuity of care, client education about medication use is crucial for adherence, and a nutritional consult helps in managing the patient's diet. However, insurance review for reimbursement is not typically part of the clinical pathway as it pertains to financial aspects and is usually handled by billing departments or external agencies. Therefore, the correct answer is 'insurance review for reimbursement.'
3. Which of the following adverse effects should the client on Floxin be alerted to?
- A. stunting of height in teens and young adults
- B. propensity for anovulatory uterine bleeding
- C. intractable diarrhea
- D. tendon rupture
Correct answer: tendon rupture
Rationale: The correct answer is tendon rupture. Floxin is a quinolone antibiotic commonly used in respiratory infections and pelvic/reproductive infections. One of the rare adverse effects associated with quinolones is tendon sheath rupture, often affecting the Achilles tendon. Therefore, patients taking Floxin should be alerted to the possibility of tendon rupture. Choices A, B, and C are incorrect as they are not typically associated with Floxin use and are not common adverse effects of quinolone antibiotics. Stunting of height is not a recognized adverse effect of Floxin. Anovulatory uterine bleeding is not a known side effect of quinolones. Intractable diarrhea is not a common adverse effect of Floxin.
4. Ashley and her boyfriend Chris, both 19 years old, are transported to the Emergency Department after being involved in a motorcycle accident. Chris is badly hurt, but Ashley has no apparent injuries, though she appears confused and has trouble focusing on what is going on around her. She complains of dizziness and nausea. Her pulse is rapid, and she is hyperventilating. The nurse should assess Ashley’s level of anxiety as:
- A. mild.
- B. moderate.
- C. severe.
- D. panic.
Correct answer: C: severe.
Rationale: Based on the symptoms described, Ashley's level of anxiety should be assessed as severe. In severe anxiety, individuals have difficulty solving problems and understanding their environment. They often exhibit somatic symptoms like dizziness, nausea, rapid pulse, and hyperventilation. In contrast, mild anxiety may lead to mild discomfort or even enhanced performance. Moderate anxiety involves grasping less information, mild difficulty in problem-solving, and slight changes in vital signs. Panic, on the other hand, is characterized by markedly disturbed behavior and a potential loss of touch with reality. Therefore, in Ashley's case, the presence of somatic symptoms and vital sign changes indicates severe anxiety.
5. While taking care of a client, the nurse thinks that physical therapy in the hospital might be beneficial to their condition. Which of the following is the ideal referral process?
- A. Transport the client to the physical therapy room for treatment after receiving an official referral.
- B. Provide the physical therapist with the client’s medical record after the referral.
- C. Contact the client’s primary care provider to suggest a physical therapy referral.
- D. Request the client to self-refer to the physical therapist.
Correct answer: C, B, A
Rationale: The ideal referral process for a client to receive physical therapy in the hospital starts with the nurse contacting the client's primary care provider to discuss and suggest a physical therapy referral. The primary care provider should provide an official referral, which is crucial for initiating the treatment process. After obtaining the official referral, the nurse should provide the physical therapist with the client’s medical record. This step is essential for the therapist to assess the client's condition and customize the treatment plan accordingly. Once the physical therapist is informed and prepared, the nurse can then transport the client to the physical therapy room for treatment. Therefore, the correct sequence is to first contact the primary care provider (Choice C), then provide the medical record (Choice B), and finally transport the client for treatment (Choice A). Choice D, suggesting the client self-refer to the physical therapist, is incorrect as the referral process should involve healthcare professionals to ensure proper assessment and treatment planning.
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