NCLEX-PN
Health Promotion and Maintenance NCLEX PN Questions
1. The client has an order for an IV piggyback of Ceftriaxone 750mg in 50mL D5W to run over 30 minutes. What is the appropriate drip rate?
- A. 100 mL/hr
- B. 150 mL/hr
- C. 200 mL/hr
- D. 50 mL/hr
Correct answer: A
Rationale: To calculate the drip rate, you need to convert the time from minutes to hours. The formula is (Volume to be infused / Time for infusion in minutes) x (60 minutes / 1 hour). Substituting the values, (50 mL / 30 min) x (60 min / 1 hr) = 100 mL/hr. Therefore, the appropriate drip rate is 100 mL/hr. Choices B, C, and D are incorrect as they do not match the calculated drip rate. Option A, 100 mL/hr, is the correct drip rate for administering Ceftriaxone 750mg in 50mL D5W over 30 minutes.
2. A nurse provides instructions to an older adult about measures to prevent heatstroke. Which statement by the client indicates a need for further instruction?
- A. ''I should wear cool, light clothing in warm weather.''
- B. ''I need to wear a hat with a wide brim when I go outdoors.''
- C. ''I need to wear additional antiperspirant and deodorant in warm weather.''
- D. ''I should drink extra fluids during the summer.''
Correct answer: C
Rationale: As an individual ages, the number of sweat glands decreases, resulting in reduced body odor and decreased evaporative heat loss due to less sweating. The need for antiperspirants and deodorants is reduced in older adults. Therefore, the statement 'I need to wear additional antiperspirant and deodorant in warm weather' indicates a need for further instruction. Older adults should focus on wearing cool, light clothing in warm weather to prevent overheating, wearing a hat with a wide brim when outdoors to protect from the sun's rays, and staying hydrated by drinking extra fluids during the summer. These measures are more effective in preventing heatstroke in older adults compared to using additional antiperspirants and deodorants, which are not necessary.
3. While assisting with data collection on a client, a nurse hears a bruit over the abdominal aorta. What action should the nurse prioritize based on this finding?
- A. Document the finding
- B. Palpate the area for a mass
- C. Notify the healthcare provider
- D. Percuss the abdomen to check for tympany
Correct answer: C
Rationale: Detection of a bruit over the aorta during abdominal assessment may indicate the presence of an aneurysm. The nurse's priority action should be to notify the healthcare provider to further evaluate the situation. Palpating the area or percussing the abdomen could potentially increase the risk of an aneurysm rupture. While documenting the finding is important, the priority is to ensure timely intervention by involving the healthcare provider.
4. A nurse is planning care for a hospitalized toddler. To best maintain the toddler's sense of control and security and ease feelings of helplessness and fear, the nurse should perform which action?
- A. Allow the toddler to play with other children in the nursing unit playroom.
- B. Spend as much time as possible with the toddler.
- C. Allow the toddler to select toys from the nursing unit playroom that can be brought into the toddler's hospital room.
- D. Keep hospital routines as similar as possible to those at home.
Correct answer: D
Rationale: The best action for the nurse to take to help a hospitalized toddler maintain a sense of control and security and ease feelings of helplessness and fear is to keep hospital routines as similar as possible to those at home. By incorporating the toddler's usual rituals and routines from home into nursing care activities, the nurse can reduce the stress of hospitalization. This approach gives the toddler a sense of familiarity, control, and security, which can alleviate feelings of helplessness and fear. Allowing the toddler to play with other children in the nursing unit playroom and selecting toys are beneficial activities, but maintaining hospital routines similar to those at home is the most effective way to support the toddler's emotional well-being during hospitalization.
5. A nurse preparing to examine a client’s eyes plans to perform a confrontation test. The nurse tells the client that this test measures which aspect of vision?
- A. Near vision
- B. Color vision
- C. Distant vision
- D. Peripheral vision
Correct answer: D
Rationale: The correct answer is D: Peripheral vision. The confrontation test is a gross measure of peripheral vision. It compares the client’s peripheral vision with the nurse’s, assuming that the nurse’s vision is normal. During the test, the nurse positions themselves at eye level with the client, about 2 feet away, and directs the client to cover one eye with an opaque card. The nurse covers the eye opposite the client’s covered one and slowly moves a target (like a pencil) from the periphery in several directions. The client is asked to indicate when they see the target, which should coincide with when the nurse sees it. Near vision is tested using a handheld vision screener with various sizes of print, color vision with the Ishihara test, and distant vision with a Snellen chart. Therefore, choices A, B, and C are incorrect as they do not measure peripheral vision, which is the focus of the confrontation test.
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