NCLEX-RN
Health Promotion and Maintenance NCLEX RN Questions
1. Which of the following conditions may cause an increased respiratory rate?
- A. Stooped posture
- B. Narcotic analgesics
- C. Injury to the brain stem
- D. Anemia
Correct answer: D
Rationale: Anemia can lead to an increased respiratory rate. In anemia, there are decreased levels of hemoglobin in red blood cells, which are responsible for carrying oxygen to the body's tissues. To compensate for the reduced oxygen-carrying capacity, the body increases the respiratory rate to bring in more oxygen. Stooped posture (Choice A) is not directly related to an increased respiratory rate. Narcotic analgesics (Choice B) are more likely to cause a decreased respiratory rate due to their central nervous system depressant effects. Injury to the brain stem (Choice C) can affect respiratory function but may not necessarily lead to an increased respiratory rate.
2. Your patient has been diagnosed with a left ankle sprain. On the discharge instructions, the physician has prescribed the RICE protocol. This acronym stands for:
- A. Rest, Ice, Compression, Elevation
- B. Radiology, Ice, Compression, Elevation
- C. Rest, Ice, Cast, Elevation
- D. Radiology, Ice, Cast, Elevation
Correct answer: A
Rationale: The correct answer is Rest, Ice, Compression, Elevation. This acronym, RICE, is commonly used for the treatment of injuries like an ankle sprain. Rest allows the injured area to heal, Ice helps reduce swelling and pain (20 minutes on each hour while awake), Compression is usually achieved with an elastic bandage to minimize swelling, and Elevation of the foot above the level of the heart assists in reducing swelling and promoting healing. Choices B, C, and D are incorrect because they include irrelevant terms like Radiology and Cast, which are not part of the standard treatment protocol for an ankle sprain.
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. Which of the following is an example of a breach of a client's right to privacy?
- A. A nurse who is not caring for the client reads the client's personal information in the chart
- B. A client is not allowed to keep a copy of their original medical record
- C. A nurse files an incident report about a client that is reviewed with all staff at a meeting
- D. A client's photograph is used without permission for the hospital newsletter
Correct answer: D
Rationale: A breach of a client's right to privacy can occur when their personal information is used or disclosed without their consent. In this scenario, using a client's photograph without permission for the hospital newsletter violates their privacy rights. It is important to respect a client's confidentiality and seek their consent before using their personal information. Choices A, B, and C do not directly relate to breaching a client's right to privacy. Reading a client's personal information in their chart, not allowing a client to keep a copy of their medical record, and filing an incident report about a client do not necessarily violate their privacy rights as long as the information is handled appropriately and within legal and ethical boundaries.
5. A 3-year-old pediatric patient's mother would like to stay at the patient's bedside throughout the night as the patient seems calmer when she is present. What is the most caring and appropriate response?
- A. Reinforce visiting hours
- B. Allow her to stay for a short period beyond normal hours
- C. Allow her to stay throughout the night
- D. Offer to get bedding for a couch in the waiting room
Correct answer: C
Rationale: Allowing the mother to stay throughout the night is the most caring and appropriate response in this situation. Pediatric facilities often recognize the crucial role parents play in their child's care and are supportive of unlimited visitation. Allowing the mother to stay can help maintain the child's calmness and enhance the bond between the family and healthcare team. Reinforcing visiting hours (Choice A) may not address the specific needs of this situation where the child benefits from the mother's presence. Allowing her to stay for a short period beyond normal hours (Choice B) may not fully address the need for her continuous presence. Offering to get bedding for a couch in the waiting room (Choice D) may not be necessary if the mother can stay with her child in the patient's room.
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