NCLEX NCLEX-RN
Health Promotion and Maintenance NCLEX RN Questions
1. Mr. N is a client who entered the hospital with a diagnosis of diabetic ketoacidosis. The nurse enters his room to check his vital signs and finds him breathing at a rate of 32 times per minute; his respirations are deep and regular. Which type of respiratory pattern is Mr. N most likely exhibiting?
- A. Kussmaul respirations
- B. Cheyne-Stokes respirations
- C. Biot's respirations
- D. Cluster breathing
Correct answer: Kussmaul respirations
Rationale: Mr. N is exhibiting Kussmaul respirations, characterized by rapid, deep, and regular breathing. This type of respiratory pattern is commonly seen in metabolic acidosis, such as in diabetic ketoacidosis. Kussmaul respirations are a form of hyperventilation, leading to the elimination of carbon dioxide from the body. Choice B, Cheyne-Stokes respirations, is characterized by alternating periods of deep, rapid breathing followed by periods of apnea and is not typically associated with diabetic ketoacidosis. Choice C, Biot's respirations, involve irregular breathing patterns with periods of apnea and are not reflective of the described breathing pattern. Cluster breathing, as mentioned in Choice D, is not a recognized term in respiratory patterns and does not describe the breathing pattern observed in Mr. N.
2. Mr. Freeman has difficulty getting out of bed. The nurse should encourage Mr. Freeman to ______________.
- A. ask for assistance before getting out of bed.
- B. remain in bed because it is safer and he will not fall.
- C. instruct him to stand up quickly from the bed.
- D. lean forward and push up and off the bed.
Correct answer: ask for assistance before getting out of the bed.
Rationale: The nurse should encourage Mr. Freeman to use his call bell and ask for assistance before getting out of bed. This can prevent him from falling. Patients should not stay in bed; they should be encouraged to get out of bed as much as possible to prevent complications like pressure ulcers and muscle weakness. Instructing a patient to stand up quickly from the bed is unsafe as it can lead to dizziness and falls. Similarly, leaning forward and pushing off the bed can increase the risk of falls and should be avoided. Asking for assistance is the safest and most appropriate option to ensure patient safety and prevent accidents.
3. The nurse is preparing to assess a hospitalized patient who is experiencing significant shortness of breath. How should the nurse proceed with the assessment?
- A. Have the patient lie down to obtain an accurate cardiac, respiratory, and abdominal assessment.
- B. Obtain a thorough history and physical assessment from the patient’s family member.
- C. Immediately perform a complete history and physical assessment to obtain baseline information.
- D. Examine the body areas relevant to the problem and complete the rest of the assessment after the problem has resolved.
Correct answer: Examine the body areas relevant to the problem and complete the rest of the assessment after the problem has resolved.
Rationale: When assessing a patient experiencing significant shortness of breath, it is crucial to prioritize the evaluation of areas directly related to the problem. Having the patient lie down may exacerbate the breathing difficulty. Therefore, the nurse should focus on examining the body areas pertinent to the issue, such as the respiratory and cardiac systems. Completing the rest of the assessment can be deferred until after addressing the immediate problem. Obtaining a complete history or involving family members should come after addressing the acute issue to ensure the patient's safety and comfort.
4. The clinic nurse reviews the record of an infant and notes that the primary healthcare provider has documented a diagnosis of suspected Hirschsprung's disease. The nurse reviews the assessment findings documented in the record, knowing that which sign most likely led the mother to seek healthcare for the infant?
- A. Diarrhea
- B. Projectile vomiting
- C. Regurgitation of feedings
- D. Foul-smelling, ribbon-like stools
Correct answer: Foul-smelling, ribbon-like stools
Rationale: Hirschsprung's disease, also known as congenital aganglionosis or aganglionic megacolon, is a congenital anomaly characterized by an absence of ganglion cells in the rectum and other areas of the affected intestine. A key clinical manifestation of Hirschsprung's disease is chronic constipation that starts in the first month of life, leading to pellet-like or ribbon-like stools that have a foul smell. Another sign is the delayed passage or absence of meconium stool in the neonatal period. In addition to foul-smelling, ribbon-like stools, bowel obstruction (especially in the neonatal period), abdominal pain and distention, and failure to thrive are also common clinical manifestations of this disorder. Options A, B, and C are not typically associated with Hirschsprung's disease, making them incorrect choices in this scenario.
5. While caring for a patient with respiratory disease, the nurse observes that the patient's SpO2 drops from 93% to 88% while the patient is ambulating in the hallway. What is the priority action of the nurse?
- A. Notify the healthcare provider
- B. Document the response to exercise
- C. Administer the PRN supplemental O2
- D. Encourage the patient to pace activity
Correct answer: Administer the PRN supplemental O2
Rationale: The drop in SpO2 to 88% indicates that the patient is hypoxemic and needs supplemental oxygen when exercising. Administering PRN supplemental oxygen is the priority action to correct the hypoxemia and ensure adequate oxygenation during activity. Notifying the healthcare provider can be done after stabilizing the patient's oxygen levels. Documenting the response to exercise is important but secondary to addressing the immediate hypoxemia. Encouraging the patient to pace activity is not sufficient to address the acute drop in SpO2 and provide the necessary oxygen support.
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