NCLEX NCLEX-PN
Health Promotion and Maintenance NCLEX PN Questions
1. While reviewing a client’s health care record, a nurse notes documentation of the presence of borborygmus on abdominal assessment. Which finding does the nurse expect to note when auscultating the client’s bowel sounds?
- A. Hypoactive bowel sounds
- B. Low-pitched bowel sounds
- C. Hyperactive bowel sounds
- D. An absence of bowel sounds
Correct answer: Hyperactive bowel sounds
Rationale: Borborygmus, a type of hyperactive bowel sound, is fairly common. It indicates hyperperistalsis, and the client may describe it as a growling stomach. Hyperactive bowel sounds are loud, high-pitched, and rushing sounds. Hypoactive bowel sounds are low-pitched and may occur post-surgery or with peritoneal inflammation. Low-pitched bowel sounds are not typically associated with borborygmus. An absence of bowel sounds indicates a potentially serious issue like an ileus, where bowel motility is decreased or absent.
2. When auscultating breath sounds, the nurse auscultates over the following locations:
- A. Trachea and lateral areas of thoracic cage
- B. Anterior and posterior aspects of all lung fields
- C. The mid section as well as the lateral section of the lungs
- D. The mid-clavicular to mid-axillary lines comparing side to side
Correct answer: Anterior and posterior aspects of all lung fields
Rationale: The correct answer is B: Anterior and posterior aspects of all lung fields. When auscultating breath sounds, it is essential to listen to the front (anterior) and back (posterior) aspects of all lung fields. This comprehensive approach allows for a thorough assessment of breath sounds throughout the lungs. Choices A, C, and D are incorrect. Choice A is too limited as it only focuses on the trachea and lateral areas, not covering all lung fields. Choice C is also too limited, referring to specific sections of the lungs (mid section and lateral section). Choice D is incorrect as it suggests comparing specific lines on the chest (mid-clavicular to mid-axillary), which is not a standard practice for auscultating breath sounds.
3. When determining a fetal heart rate (FHR) and noting accelerations from the baseline rate when the fetus is moving, a nurse interprets this finding as:
- A. A reassuring sign
- B. An indication of the need to contact the physician
- C. An indication of fetal distress
- D. A nonreassuring sign
Correct answer: A reassuring sign
Rationale: When a nurse notes accelerations from the baseline rate of the fetal heart rate, particularly when they occur with fetal movement, it is considered a reassuring sign. This indicates a healthy response to fetal activity. Reassuring signs in FHR monitoring include an average rate between 120 and 160 beats/min at term, a regular rhythm with slight fluctuations, accelerations from the baseline rate (often associated with fetal movement), and the absence of decreases from the baseline rate. Choices B, C, and D are incorrect because accelerations in FHR with fetal movement are not indicative of the need to contact the physician, fetal distress, or a nonreassuring sign. These signs would typically be associated with other abnormal FHR patterns that would warrant further assessment and intervention.
4. The LPN needs to determine the client’s respiratory rate. What is the best technique to do this?
- A. Tell the client you need to count their respiratory rate.
- B. Subtly watch the client from across the room when they are doing an activity.
- C. Ask the client to sit still for 30 seconds.
- D. Count respirations while pretending to check the client’s pulse.
Correct answer: Count respirations while pretending to check the client’s pulse.
Rationale: The best technique to determine a client's respiratory rate is to count respirations while pretending to check the client’s pulse. You should not inform the client that you are counting their respirations, as this might lead to a change in their breathing pattern. Pretending to check the pulse allows you to be close to the client without revealing that you are assessing their respiratory rate. Asking the client to sit still may not be as effective, as it may cause them to concentrate on their breathing. Watching from across the room may not provide an accurate assessment of respirations, as they might be difficult to observe.
5. Which information should be reported to the state Board of Nursing?
- A. The facility fails to provide literature in both Spanish and English.
- B. The narcotic count has been incorrect on the unit for the past 3 days.
- C. The client fails to receive an itemized account of his bills and services received during his hospital stay.
- D. The nursing assistant assigned to the client with hepatitis fails to feed the client and give the bath.
Correct answer: The narcotic count has been incorrect on the unit for the past 3 days.
Rationale: The correct answer is 'The narcotic count has been incorrect on the unit for the past 3 days.' This information should be reported to the state Board of Nursing as it involves medication errors and potential drug diversion, which are serious issues that fall under the jurisdiction of the Board. Reporting medication discrepancies and errors in narcotic counts is crucial for patient safety and regulatory compliance. Choices A, C, and D involve different types of issues that are not within the direct purview of the Board of Nursing. Providing literature in multiple languages (Choice A), addressing billing practices (Choice C), and resolving staff performance issues (Choice D) should be handled internally or reported to the appropriate departments or authorities, such as the Joint Commission or the charge nurse.
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