NCLEX-PN health promotion practice questions, set 3
NCLEX-PN · health promotion
NCLEX-PN health promotion practice questionsset 3
You teach screening, development, and prevention in the words a patient can use. Five of the 15 questions include the correct answer and rationale. The other ten keep answers in the study hub. Continue with the NCLEX-PN exam guide or more NCLEX-PN practice questions.
Five health promotion questions with answers
Cover the key. Write the first action. Then open the rationale and name why the other choices fail.
Question 1
When planning for the physical assessment of the woman, the nurse ensures that which occurs?
A. The woman is examined by a female health care provider.
B. The woman's husband remains in the examining room at all times.
C. The woman is examined without any other people in the examining room.
D. Written permission is obtained from the woman to obtain subjective health data.
Show answer and rationale
Correct answer: A — The woman is examined by a female health care provider.
In many cultures, including Muslim, Hindu, and Latino, modesty is important, and exposure of a woman's genitals to men is considered demeaning. To respect the patient's cultural beliefs and modesty, it is best for a female health care provider to perform the examination. This practice helps to ensure the patient's comfort and adherence to cultural norms. Having the woman examined without any other people in the room (Choice C) may not address the cultural sensitivity required for this situation. Having the woman's husband remain in the examining room at all times (Choice B) may not align with the patient's cultural preferences and may cause discomfort. Written permission from the woman to obtain subjective health data (Choice D) is not directly related to ensuring a culturally sensitive physical assessment in this context.
Question 2
What are the basic reasons American families are having difficulty adequately performing their vital health care function?
A. structure of the health care system and family structure
B. psychological factors affecting men and women seeking health care
C. conditions labeled as disabilities and considered too time-consuming
D. health care organizations (HMOs) and disconnected families
Show answer and rationale
Correct answer: A — structure of the health care system and family structure
The correct answer is the 'structure of the health care system and family structure'. Scholars suggest that the reasons families are having difficulty providing health care for their members lie with both the structure of the health care system and the family structure. Major factors explaining differences in utilization patterns of medical services include the lack of healthcare insurance coverage, lack of services for special populations (such as teenage males), perception by families of the health care system and the health care provider, and lack of partnership between health care providers and families in mutually addressing health care issues. Choices B, C, and D are incorrect as they do not address the fundamental reasons related to the health care system and family structure as discussed in the provided extract.
Question 3
While performing a physical assessment on a 6-month-old infant, the nurse observes head lag. Which of the following nursing actions should the nurse perform first?
A. Ask the parents to allow the infant to lie on his stomach to promote muscle development.
B. Notify the physician because a developmental or neurological evaluation is indicated.
C. Document the findings as abnormal in the nurse's notes.
D. Explain to the parents that their child is likely to have developmental delays.
Show answer and rationale
Correct answer: B — Notify the physician because a developmental or neurological evaluation is indicated.
Head lag should be completely resolved by 4 months of age. Continuing head lag at 6 months of age indicates the need for further developmental or neurological evaluation. Laying the infant on his stomach promotes muscle development of the neck and shoulder muscles, but because of the age of this child, a referral should be the first action. The findings are abnormal for a 6-month-old infant. Significant head lag can be seen in infants with Down syndrome and hypoxia, as well as neurological and other metabolic disorders. While some of these disorders might include developmental delays, stating this to the parents without a proper evaluation can cause unnecessary distress. The priority is to identify the cause of the head lag through a medical evaluation before discussing potential outcomes with the parents.
Question 4
While taking the vital signs of a pregnant client admitted to the labor unit, a nurse notes a temperature of 100.6°F, pulse rate of 100 beats/min, and respirations of 24 breaths/min. What is the most appropriate nursing action based on these findings?
A. Notify the registered nurse of the findings.
B. Document the findings in the client's medical record.
C. Recheck the vital signs in 1 hour.
D. Continue collecting subjective and objective data.
Show answer and rationale
Correct answer: A — Notify the registered nurse of the findings.
The correct answer is to notify the registered nurse of the findings. In a pregnant client, the normal temperature range is 98°F to 99.6°F, with a pulse rate of 60 to 90 beats/min and respirations of 12 to 20 breaths/min. A temperature of 100.4°F or higher, along with an increased pulse rate and faster respirations, suggests a possible infection. Immediate notification of the registered nurse is crucial for further evaluation and intervention. While documenting the findings is essential, the priority lies in promptly escalating abnormal vital signs for assessment and management. Rechecking vital signs in 1 hour may delay necessary interventions for a deteriorating condition. Continuing to collect data is relevant but should not delay informing the registered nurse when abnormal vital signs are present.
Question 5
A nurse is supervising a student in preparing the physical environment for an interview with a client. Which action by the student is correct?
A. Setting the room temperature at a comfortable level
B. Placing a chair for the client across from the nurse's desk
C. Providing seating for the client so that the client faces a strong light
D. Setting up seating so that the client and nurse are not at eye level
Show answer and rationale
Correct answer: A — Setting the room temperature at a comfortable level
When preparing the physical environment for an interview with a client, it is crucial to ensure the client's comfort. Setting the room temperature at a comfortable level is essential for the client's well-being. Additionally, providing privacy, sufficient lighting, and removing distractions are crucial factors. It is recommended to maintain a distance of around 4 to 5 feet between the client and the nurse. Seating should be arranged so that the client and nurse are at eye level to facilitate effective communication and prevent barriers. Placing a chair across from the nurse's desk may create a physical barrier, positioning the client to face a strong light can be uncomfortable and distracting, and setting up seating so that the client and nurse are not at eye level may impede effective communication.
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Question 6
An Rh-negative woman with previous sensitization has delivered an Rh-positive fetus. Which of the following nursing actions should be included in the client's care plan?
A. emotional support to help the family cope with feelings of guilt about the infant's condition
B. administration of MICRhoGam to the woman within 72 hours of delivery
C. administration of Rh-immune globulin to the newborn within 1 hour of delivery
D. lab analysis of maternal Direct Coombs' test
Correct answer:
In this scenario, the Rh-negative woman has been sensitized, posing a risk to any Rh-positive fetus she delivers. The most appropriate nursing action is to provide emotional support to help the family cope with the infant's condition. This includes addressing potential outcomes like death or neurological damage. Administering MICRhoGam (Choice B) to a sensitized woman is not recommended; it is only given post-abortion or ectopic pregnancy to prevent sensitization. Rh-immune globulin is not administered to the newborn (Choice C) in this case. Analyzing the maternal Direct Coombs' test (Choice D) is unnecessary; instead, an Indirect Coombs' test is used to assess sensitization. Therefore, the correct nursing action is to offer emotional support to the family, acknowledging the challenges they may face.
A nurse assisting with data collection is testing the cochlear portion of the acoustic nerve (cranial nerve VIII). Which action does the nurse take to test this nerve?
A. Asking the client to raise their eyebrows and looking for symmetry
B. Asking the client to clench the teeth, then palpating the masseter muscles just above the mandibular angle
C. Asking the client to close the eyes and then identify light and sharp touch with a cotton ball and a pin on both sides of the face
D. Asking the client to close their eyes and then indicate when a ticking watch is heard as the nurse brings the watch closer to the client's ear
Correct answer:
To test the cochlear portion of the acoustic nerve (cranial nerve VIII), the nurse should have the client close their eyes and indicate when a ticking watch is heard as the nurse moves the watch closer to the client's ear. This action assesses the client's ability to perceive auditory stimuli, as the cochlear portion of the acoustic nerve is responsible for hearing. Choices A, B, and C are incorrect. Asking the client to raise their eyebrows to check for symmetry is a method to test the facial nerve (cranial nerve VII). Asking the client to clench their teeth and palpating the masseter muscles tests the motor component of the trigeminal nerve. Having the client identify light and sharp touch on both sides of the face is a way to test the sensory component of the trigeminal nerve (cranial nerve V).
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:
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.
A nurse assisting with data collection is preparing to auscultate for bowel sounds. The nurse should use which technique?
A. Begin in the right lower quadrant.
B. Use the bell end of the stethoscope.
C. Hold the stethoscope lightly against the skin.
D. Listen for at least 5 minutes before deciding that bowel sounds are absent.
Correct answer:
To auscultate for bowel sounds, the nurse should use the diaphragm end piece of the stethoscope as bowel sounds are relatively high pitched. The stethoscope should be held lightly against the skin to avoid stimulating more bowel sounds. The nurse should begin in the right lower quadrant at the ileocecal valve, where bowel sounds are normally present. It is recommended to listen for 5 minutes before deciding that bowel sounds are absent to ensure a thorough assessment. Choice B is incorrect because the bell end is used for low-pitched sounds such as heart sounds. Choice C is incorrect as holding the stethoscope firmly and deeply can cause unnecessary bowel sound stimulation. Choice D is incorrect as listening for 1 minute is insufficient to determine the presence or absence of bowel sounds.
A preschooler has successfully completed the test item 'counts 5 blocks' on the Denver II test. This pass is evidence of which of the following developmental concepts?
A. centration
B. causality
C. nonreversibility
D. conservation
Correct answer:
The ability of a preschooler to move five blocks to a piece of paper and state there are five blocks on the paper is evidence that the preschooler has the ability of conservation. This concept refers to the fact that the quantity of something doesn't change just because the shape, contour, and so on has changed. Five blocks are still five blocks, whether they are lying beside the paper, stacked on the paper, or moved to the paper. Centration is the ability to concentrate on one feature of a situation while neglecting all other aspects. Causality is based on the sequence of events, one event ordinarily following another. Non-reversibility refers to the inability of preschoolers to reverse their operations. They are only able to think forward, not retrace or reverse their thought processes.
The LPN is about to give 100 mg Lopressor (metoprolol) to a client. Before administering the drug, they take the patient's vitals, which are as follows:
Pulse: 58
Blood Pressure: 90/62
Respirations: 18/minute
What action should the LPN take?
A. Give the client half the prescribed dose and report the findings to the RN on duty.
B. Give the client double the dose and report the findings to the RN on duty.
C. Administer the drug and report the findings to the RN on duty.
D. Hold the drug and report the findings to the RN on duty.
Correct answer:
Lopressor is given to treat hypertension, and a pulse of 58 and a blood pressure of 90/62 are considered low. To prevent the client from bottoming out, the drug should be held, and the findings reported to the RN, who should consult with the attending physician. LPNs should never adjust client dosing, as that is outside of their scope of practice. It is crucial to follow facility guidelines, which often recommend holding blood pressure medication at 60 bpm and a systolic pressure of 90 or less. By holding the drug and notifying the RN, the LPN ensures the client's safety and allows for appropriate assessment and decision-making by the healthcare team. Giving half the dose or double the dose without proper authorization can lead to serious complications and is considered unsafe practice.
A nurse notes the presence of variable decelerations on the fetal heart rate monitor strip and suspects cord compression. The nurse should immediately perform which action?
A. Insert a gloved finger into the mother's vagina to feel for cord compression
B. Position the mother so that her hips are elevated
C. Notify the registered nurse
D. Perform a vaginal examination on the mother
Correct answer:
When variable decelerations on the fetal heart rate monitor strip suggest cord compression, the immediate action the nurse should take is to reposition the mother to alleviate the compression. Elevating the mother's hips or changing her position can help shift the fetal presenting part and relieve pressure on the cord. This action aims to improve or resolve the variable decelerations. Contacting the registered nurse may be necessary, but it is not the immediate action required in this situation. Performing a vaginal examination is contraindicated due to the potential risk of further compromising blood flow through the umbilical cord. Inserting a gloved finger into the mother's vagina to feel for the cord is also not recommended as it poses a similar risk of exacerbating the situation.
Which of the following is not a nursing responsibility when preparing the client for central line insertion?
A. advancing the guidewire
B. explaining the procedure to the client
C. maintaining sterile technique
D. ensuring necessary consents are signed
Correct answer:
When preparing a client for central line insertion, nursing responsibilities include explaining the procedure to the client, ensuring necessary consents are signed according to the facility policy, and maintaining sterile technique when preparing the equipment and supplies. Advancing the guidewire is typically performed by the practitioner inserting the central line, not the nurse. It requires specialized training and expertise beyond the scope of nursing practice. Therefore, the correct answer is advancing the guidewire. Option A is the correct answer because it delineates an activity that is not within the usual scope of nursing practice during central line insertion preparation. Options B, C, and D are incorrect as they reflect essential nursing responsibilities in this context.
A client is brought to the emergency department after a motor vehicle accident. The client is alert and cooperative but has sustained multiple fractures of the legs. How should the nurse proceed with data collection?
A. Collect health history information first while initiating emergency measures.
B. Ask health history questions while performing the examination and initiating emergency measures.
C. Collect all information requested on the history form, including social support, strengths, and coping patterns.
D. Perform emergency measures and delay health history questions until after treating the fractures in the operating room.
Correct answer:
When a client is alert and cooperative but has sustained multiple fractures, the nurse should prioritize obtaining health history information while performing the examination and initiating emergency measures. This approach allows the nurse to gather essential information without delaying immediate interventions. Option A is incorrect because collecting health history information before addressing the immediate need for treatment may lead to a delay in necessary interventions. Option C is incorrect as it includes non-urgent aspects of data collection that are not a priority in this critical situation. Option D is incorrect because delaying health history questions until after treating the fractures may result in missing crucial information essential for the client's immediate care.
Which of the following is least appropriate when caring for a stable postpartum client?
A. Assess the location and height of the fundus.
B. Conduct a family assessment, including the mother's future plans for returning to work, if applicable.
C. Monitor the client for bleeding.
D. Provide perineal care.
Correct answer:
Providing perineal care is not the least appropriate when caring for a stable postpartum client. Perineal care is essential for maintaining hygiene and preventing infection after delivery. Assessing the location and height of the fundus helps in monitoring postpartum uterine involution, which is crucial for assessing the recovery progress. Conducting a family assessment, including the mother's future plans for returning to work, is important for understanding the support system available for the mother during the postpartum period. Monitoring the client for bleeding is critical to promptly identify and address any postpartum hemorrhage. Therefore, providing perineal care is the least appropriate option among the choices provided as it is a fundamental aspect of postpartum care.
NCLEX-PN health promotion practice questions, set 3 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
No. Nursier is independent practice. Register through the official path named on the NCLEX-PN exam guide.
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