NCLEX NCLEX-PN
Health Promotion and Maintenance NCLEX PN Questions
1. The nurse is observing a client self-administer two crushable medications through their G-tube. Which of the following would indicate a need for further instruction?
- A. The client flushes the G-tube before administering the medications, in between the two medications, and after the medications.
- B. The client states they will remain in the Semi-Fowler’s position for 30 minutes following the administration of the medications.
- C. The client mixes each medication separately in warm water.
- D. The client mixes their medications with their tube-feeding formula.
Correct answer: The client mixes their medications with their tube-feeding formula.
Rationale: The correct answer is that the client mixes their medications with their tube-feeding formula. Medications should not be mixed with tube-feeding formula or other medications as it may alter their effectiveness. The G-tube should be flushed before, between, and after the medications to prevent clogging and ensure proper administration. The client should remain in the Semi-Fowler’s position for at least 30 minutes after medication administration to prevent reflux. Choice B is correct as it aligns with the proper post-administration positioning. Choices A and C are incorrect as flushing the G-tube before, between, and after medications, and mixing each medication separately in warm water are appropriate procedures that do not indicate a need for further instruction.
2. Levothyroxine (Synthroid) is the drug of choice for thyroid replacement therapy in clients with hypothyroidism because:
- A. it is chemically stable, nonallergenic, and can be administered orally once a day.
- B. it is available in a wide range of concentrations to meet individual client requirements.
- C. it is a prodrug of T3.
- D. it has a long half-life.
Correct answer: it is chemically stable, nonallergenic, and can be administered orally once a day.
Rationale: Levothyroxine (Synthroid) is the preferred medication for hypothyroidism due to its chemical stability, nonallergenic properties, and convenient once-daily oral administration. It is safe and effective with minimal side effects when appropriately dosed. Choice B is incorrect because while Levothyroxine is available in various concentrations, it is not the reason it is the drug of choice; the primary reason is its stability and nonallergenic nature. Choice C is wrong as Levothyroxine (T4) is not a prodrug of T3; it is converted to T3 in the body. Option D is inaccurate because Levothyroxine has a long half-life (around 7 days), enabling once-daily dosing, as opposed to a short half-life.
3. What is the next step for a 64-year-old male diagnosed with COPD and CHF who shows a 10 lbs increase in total body weight over the last few days?
- A. Contact the patient’s physician immediately.
- B. Check the intake and output on the patient’s flow sheet.
- C. Encourage the patient to ambulate to reduce lower extremity edema.
- D. Check the patient’s vitals every 2 hours.
Correct answer: Check the intake and output on the patient’s flow sheet.
Rationale: In a patient with COPD and CHF experiencing a sudden increase in total body weight, the priority is to check the intake and output on the patient’s flow sheet to evaluate fluid balance. This assessment helps determine if the weight gain is due to fluid retention, which can exacerbate CHF. Contacting the physician may be necessary based on the intake and output findings. While encouraging ambulation is beneficial for circulation, it may not address the root cause of fluid retention. Checking vitals every 2 hours is important for monitoring stability but may not pinpoint the reason behind the weight gain.
4. A mother has come to the pediatric clinic concerned about the recent outbreak of West Nile Virus. The ages of her children are 5, 7, and 10. The mother has asked the nurse what she can do to prevent her children from contracting this illness. Which piece of information is best to provide the mother with?
- A. The children should wear long sleeves and long pants while outside.
- B. Apply insect repellent containing DEET when the children are outside.
- C. Remove standing water from the property.
- D. All of the above.
Correct answer: D
Rationale: The best advice to provide to the mother is 'All of the above.' It is recommended that the children wear insect repellent containing DEET and long-sleeved shirts and long pants when they are outside. This helps in preventing mosquito bites, which can transmit the West Nile Virus. Additionally, removing standing water from areas where the children play can help decrease the number of breeding mosquitoes, reducing the risk of contracting the virus. These methods work in combination to provide effective prevention against the West Nile Virus, making 'All of the above' the correct choice. Choices A, B, and C individually address important prevention measures, but a combination of all three strategies is the most comprehensive approach to protect the children from contracting the illness.
5. A client with a history of peptic ulcer disease arrives in the emergency department complaining of weakness and states that he vomited 'a lot of dark coffee-looking stomach contents.' The client is cool and moist to the touch. BP 90/50, HR 110, RR 20, T 98. Of the following physician orders, which will the nurse perform first?
- A. Initiate oxygen at 2 liters/nasal cannula.
- B. Start an IV of NS at 150 ml/hr
- C. Insert NG tube to low suction
- D. Attach the client to the ECG monitor
Correct answer: Initiate oxygen at 2 liters/nasal cannula.
Rationale: The correct answer is to initiate oxygen at 2 liters/nasal cannula. The client is presenting signs of shock with hypotension, tachycardia, and cool, moist skin, which indicate poor tissue perfusion. Oxygen should be administered first to improve tissue oxygenation. While all interventions are important, oxygenation takes priority in the ABCs of emergency care. Starting an IV of NS, inserting an NG tube, and attaching the client to the ECG monitor are necessary interventions but should follow the priority of oxygen administration in this scenario.
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