NCLEX NCLEX-PN
Health Promotion and Maintenance NCLEX Questions
1. The mother of a newborn who was circumcised before discharge from the hospital calls the nurse at the pediatrician’s office and tells the nurse that she is concerned because she has noticed a yellow crust over the circumcision site. The nurse provides which information to the mother?
- A. That it could indicate a sign of an infection and the infant’s temperature should be checked every 2 hours
- B. That the crust is to be expected as a normal part of healing
- C. To bring the infant to the pediatrician's office to be checked
- D. To remove the crust, using a warm, wet face cloth and a mild soap
Correct answer: That the crust is to be expected as a normal part of healing
Rationale: After circumcision, a yellow crust may form over the circumcision site, which is a normal part of healing and should not be removed. The mother should be reassured that this crust is to be expected. Yellow crusting or discharge is not indicative of an infection, and there is no need to notify the pediatrician. Checking the infant's temperature every 2 hours is unnecessary and may cause unnecessary alarm to the mother.
2. A nurse is assisting with developing a plan of care for an older client to help maintain an adequate sleep pattern. Which action should the nurse suggest be included in the plan?
- A. Encouraging bedtime reading or listening to music
- B. Encouraging at least one daytime nap
- C. Discouraging the use of a nightlight at bedtime
- D. Discouraging social interaction, particularly at bedtime
Correct answer: A: Encouraging bedtime reading or listening to music
Rationale: To help maintain an adequate sleep pattern in older clients, it is essential to include activities that promote relaxation and a conducive sleep environment. Encouraging bedtime reading or listening to music can help the client unwind and prepare for sleep. Daytime naps should be discouraged to ensure a better nighttime sleep. Social interaction, especially positive interactions, can be beneficial and should not be discouraged. The use of a nightlight can create a safe and comfortable environment for the client, so it should not be discouraged unless specifically contraindicated.
3. In an emergency situation, the nurse determines whether a client has an airway obstruction. Which of the following does the nurse assess?
- A. ability to speak
- B. ability to hear
- C. oxygen saturation
- D. adventitious breath sounds
Correct answer: ability to speak
Rationale: In an emergency situation to assess for airway obstruction, the nurse should prioritize assessing the client's ability to speak. If a client can speak, it indicates that the airway is patent and not completely obstructed, allowing air to pass through the vocal cords for speech production. Choices B, C, and D are not the primary assessments for determining airway obstruction. Assessing the ability to hear is not directly related to an airway obstruction. While oxygen saturation and adventitious breath sounds are important in respiratory assessments, they are not the initial indicators of an airway obstruction. Oxygen saturation reflects the amount of oxygen in the blood, and adventitious breath sounds refer to abnormal lung sounds that may indicate conditions like pneumonia or bronchitis, but they do not specifically confirm airway patency.
4. Upon admission, the client expresses a desire for an extra oxygen tank in their room due to a previous breathing issue. What is the most appropriate response?
- A. “I will make sure there is always an extra oxygen tank in your room.”
- B. “I will ask the previous nurse if the extra tank was needed.”
- C. “I will need to check if your insurance benefits would cover an additional oxygen tank.”
- D. “The first priority is ensuring there are enough oxygen tanks for everyone who needs them. I am not sure we will be able to provide an extra on standby.”
Correct answer: “The first priority is ensuring there are enough oxygen tanks for everyone who needs them. I am not sure we will be able to provide an extra on standby.”
Rationale: The appropriate response in this situation is to prioritize the availability of oxygen tanks for all patients in need. While it is understandable that the client may desire an extra tank for reassurance, the healthcare facility must ensure equitable distribution based on clinical need. Option A is incorrect because promising an always available extra tank may not be feasible and can set unrealistic expectations. Option B is not the best response as it focuses on past actions rather than addressing the current situation. Option C is not the most appropriate response at this time as the client's immediate need for an extra oxygen tank is the primary concern. Therefore, the best response is to emphasize the importance of equitable distribution of resources while acknowledging the client's request for an extra tank.
5. 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.
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