NCLEX-RN
Health Promotion and Maintenance NCLEX RN Questions
1. Which nursing intervention is most appropriate to maintain the patency of a client's nasogastric tube?
- A. Maintain a constant connection to low-intermittent suction
- B. Irrigate the tube as per physician's order
- C. Suction the mouth and nose every shift
- D. Perform a daily fecal occult blood sample
Correct answer: B
Rationale: The correct answer is to irrigate the tube as per physician's order. A client with a nasogastric tube is at risk of the tube kinking or clotting off, which can lead to complications such as abdominal distention or vomiting. To ensure the patency of the tube, the nurse should follow the physician's orders and facility policy to irrigate the tube with water or a solution as needed. Maintaining a constant connection to low-intermittent suction (Choice A) is not typically done to maintain tube patency. Suctioning the mouth and nose every shift (Choice C) is not directly related to maintaining nasogastric tube patency. Performing a daily fecal occult blood sample (Choice D) is unrelated to maintaining the patency of a nasogastric tube.
2. The nurse is performing discharge teaching for Mrs. S after cardiac angioplasty. Her husband is present for the teaching. While explaining the prescription for antiplatelet medication to use at home, Mrs. S's husband states, 'I don't think I can afford to refill that medication.' What is the most appropriate response of the nurse?
- A. Don't worry, your insurance will cover it.
- B. I'll ask the physician if he can prescribe a medication that is more affordable.
- C. You should apply for Medicare to see if they can help you.
- D. This medication is essential for her care and should be given priority over all others that she is taking.
Correct answer: B
Rationale: The most appropriate response for the nurse in this situation is to offer assistance in exploring more affordable medication options. It is important to address the patient's concerns about medication costs to ensure adherence to the treatment plan. By suggesting to ask the physician if a more affordable alternative is available, the nurse shows understanding and a commitment to helping the patient access necessary medications. Choice A is incorrect because assuming insurance coverage without verifying can lead to false expectations. Choice C is incorrect as Medicare eligibility and assistance may not be applicable in this scenario. Choice D is incorrect as it does not address the financial concern raised by the husband and emphasizes the importance of the medication without offering a practical solution to affordability.
3. In which situation might an occupational health nurse consultation be necessary?
- A. A nurse is injured from using incorrect body mechanics to lift a client
- B. A nurse receives a subpoena to testify in court about a client's case
- C. A client who has been injured in a diving accident needs assistance with planning rehabilitation and surgery
- D. A nursing unit is implementing a new electronic health record system
Correct answer: A
Rationale: An occupational health nurse is involved in assessing the work environment, educating employees about safety practices, and infection control. When a nurse sustains an injury due to incorrect body mechanics, it falls under the purview of an occupational health nurse because they are responsible for documenting such incidents, providing necessary care or treatment, and ensuring that preventive measures are in place to avoid similar accidents in the future. The other options do not directly relate to the role of an occupational health nurse. Testifying in court, assisting a client with rehabilitation, or implementing a new electronic health record system are not typical scenarios where an occupational health nurse would be involved.
4. What would a healthcare professional expect to observe while assessing the growth of children during their school-age years?
- A. Decreasing amounts of body fat and muscle mass
- B. Little change in body appearance from year to year
- C. Progressive height increase of 4 inches each year
- D. Yearly weight gain of about 5.5 pounds per year
Correct answer: D
Rationale: During school-age years, children typically gain about 5.5 pounds per year and increase in height by about 2 inches annually. This steady growth pattern is expected between ages 2 to 10 years. Choice A is incorrect as children at this stage are expected to gain weight and grow in height. Choice B is incorrect as there should be noticeable changes in body appearance due to growth. Choice C is incorrect as a progressive height increase of 4 inches each year is not typical during the school-age years.
5. The nurse is speaking at a community meeting about personal responsibility for health promotion. A participant asks about chiropractic treatment for illnesses. What should be the focus of the nurse's response?
- A. Electrical energy fields
- B. Spinal column manipulation
- C. Mind-body balance
- D. Exercise of joints
Correct answer: B
Rationale: The focus of the nurse's response should be on spinal column manipulation when discussing chiropractic treatment for illnesses. Chiropractic theory emphasizes that misalignment of the vertebrae can interfere with the transmission of mental impulses between the brain and body organs, leading to diseases. Manipulation is aimed at reducing such misalignments, known as subluxations. While mind-body balance and exercise of joints are important aspects of holistic health, in the context of chiropractic treatment, the key intervention is spinal column manipulation to address vertebral misalignments. Therefore, choices A, C, and D are incorrect as they do not directly address the primary focus of chiropractic treatment.
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