NCLEX-RN health promotion practice questions, set 2
NCLEX-RN · health promotion
NCLEX-RN health promotion practice questionsset 2
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-RN exam guide or more NCLEX-RN 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
A client with hyperkalemia may exhibit peaked T waves on an electrocardiogram. This manifestation is an early sign of high potassium levels, but the diagnosis should not be based on this aspect alone. Untreated, hyperkalemia can lead to progressively worsening cardiac instability.
A. A lumbar puncture takes a sample of cerebrospinal fluid from the back, which will be analyzed by the lab.
B. The physician will insert a needle at the level of L4-L5 in the spinal cord.
C. The client should lie flat on their back for a specific period following the procedure.
D. The risks of the procedure include headache, back pain, and infection.
Show answer and rationale
Correct answer: B — The physician will insert a needle at the level of L4-L5 in the spinal cord.
A lumbar puncture is performed to obtain cerebrospinal fluid for analysis to investigate various conditions affecting the client. During the procedure, the client is typically positioned on their side or sitting leaning over a table with their back rounded. The physician inserts a needle into the back around the L4-L5 vertebrae to collect the sample. Option A is incorrect because a lumbar puncture does not draw blood but instead collects cerebrospinal fluid. Option C is incorrect as the client should not necessarily lie flat for 24 hours post-procedure. Option D is incorrect as the common risks of a lumbar puncture include headache, back pain, and potential infection, not nausea, rash, or hypotension.
Question 2
Which of the following is a true statement about assessing blood pressure by palpation?
A. Only the diastolic blood pressure can be assessed through palpation.
B. The palpation technique is most useful for infants and small children.
C. Hypertension is a common condition that might need to be assessed through blood pressure palpation.
D. Only the systolic blood pressure can be assessed through palpation.
Show answer and rationale
Correct answer: D — Only the systolic blood pressure can be assessed through palpation.
When assessing blood pressure by palpation, it is important to note that only the systolic blood pressure can be determined accurately using this method. Diastolic blood pressure cannot be reliably assessed through palpation. The palpation technique is particularly useful in situations where traditional blood pressure measurement methods are challenging, such as in infants, small children, or individuals with low blood pressure that is difficult to hear. Hypertension, a common condition characterized by elevated blood pressure, is typically assessed using auscultation rather than palpation. Therefore, the correct statement is that only the systolic blood pressure can be assessed through palpation.
Question 3
Which of the following statements best describes compartment syndrome?
A. An injury causes pain and tingling that starts in the buttock and travels down the leg.
B. An injury causes swelling within muscle tissue that leads to anoxia of nerves and muscles.
C. An injury causes permanent flexion of the interphalangeal joint, resulting in deformity.
D. An injury causes pain and swelling of the median plantar nerve.
Show answer and rationale
Correct answer: B — An injury causes swelling within muscle tissue that leads to anoxia of nerves and muscles.
Compartment syndrome is characterized by swelling and increased pressure within a muscle compartment, leading to decreased blood flow and oxygen supply to nerves and muscles. This can result from various causes, such as trauma or the application of a cast after a fracture. If left untreated, compartment syndrome can lead to tissue necrosis. Choice A is incorrect as pain and tingling starting in the buttock and traveling down the leg are not specific features of compartment syndrome. Choice C is incorrect as permanent flexion of the interphalangeal joint is unrelated to compartment syndrome. Choice D is incorrect as pain and swelling of the median plantar nerve do not describe compartment syndrome.
Question 4
A client in labor has an electronic fetal monitor attached to the abdomen, and the nurse notes that the baby's heart rate slows down during each contraction, returning to normal limits only after the contraction is complete. Which type of fetal heart rate change does this pattern describe?
A. Variable decelerations
B. Late decelerations
C. Early decelerations
D. Accelerations
Show answer and rationale
Correct answer: B — Late decelerations
Late decelerations refer to a pattern where the baby's heart rate decreases during contractions and does not return to normal until after the contraction ends. This is considered a non-reassuring sign as it indicates potential fetal distress. Late decelerations are associated with uteroplacental insufficiency, and immediate medical attention is required. Variable decelerations (Choice A) are abrupt, unpredictable decreases in the fetal heart rate, usually associated with cord compression. Early decelerations (Choice C) are usually benign and mirror the contraction pattern. Accelerations (Choice D) are reassuring signs of fetal well-being, characterized by an increase in the fetal heart rate.
Question 5
A nurse is assessing a client's pulse oximetry on the surgical unit. As part of routine interventions, the nurse turns off the exam light over the client's bed. Which of the following best describes the rationale for this intervention?
A. External light sources may cause falsely high oximetry values
B. A bright light in the client's face may cause a low pulse oximetry
C. External light sources may cause falsely low oximetry values
D. The client needs a dark and quiet room to recover and maintain proper oxygenation
Show answer and rationale
Correct answer: A — External light sources may cause falsely high oximetry values
When assessing a client's pulse oximetry values, the nurse should turn off any extra environmental lights that are unnecessary, including exam lights or over-bed lights. External light sources may cause falsely high oximetry values when the extra light interferes with the sensor of the oximeter, leading to inaccurate readings. Choice B is incorrect because a bright light in the client's face would not directly affect the pulse oximetry values. Choice C is incorrect as external light sources typically cause falsely high, not low, oximetry values. Choice D is incorrect as the primary reason for turning off the light is to prevent falsely high readings, not solely for the client's comfort.
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Question 6
A patient with bipolar disorder asks the nurse, "Why did I get this illness? I don't want to be sick."? The nurse would best respond with:
A. People who develop mental illnesses often had a very traumatic childhood experience.
B. There is some evidence that contracting a virus during childhood can lead to mental disorders.
C. Sometimes people with mental illness have an overactive immune system.
D. We don't fully understand the cause, but mental illnesses do seem to run in the family.
Correct answer:
The correct response is, 'We don't fully understand the cause, but mental illnesses do seem to run in the family.' Current research suggests that while genetics play a role in the development of mental illnesses like bipolar disorder, it is not the sole factor. Environmental influences, life experiences, and other non-genetic factors also contribute significantly to the manifestation of mental disorders. Choices A, B, and C provide incorrect information that is not supported by current research. Traumatic childhood experiences, contracting a virus during childhood, and an overactive immune system are not established causes of bipolar disorder or mental illnesses in general.
Mrs. G is seen for follow-up after testing for chronically high blood glucose levels. Her physician diagnoses her with type 1 diabetes. Which of the following information is part of this client's education about this condition?
A. Type 1 diabetes occurs due to increased carbohydrate intake and lack of exercise
B. Type 1 diabetes is managed through diet and exercise
C. Type 1 diabetes is caused by destruction of beta cells in the pancreas
D. Type 1 diabetes leads to the body's cells rejecting insulin
Correct answer:
Type 1 diabetes is an autoimmune condition where the immune system attacks and destroys the beta cells in the pancreas, leading to a lack of insulin production. Insulin is essential for regulating blood glucose levels and enabling cells to use glucose for energy. Understanding that type 1 diabetes results from the destruction of beta cells helps patients comprehend the need for insulin replacement therapy. Choices A and B are incorrect as type 1 diabetes is not primarily caused by diet or exercise habits. Choice D is incorrect because type 1 diabetes is not about the body's cells rejecting insulin but rather the lack of insulin production due to beta cell destruction.
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:
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.
A client has a right-sided chest tube with 50 cc of serosanguinous fluid in the collection chamber and air bubbles are collecting in the water seal chamber. What is the most appropriate action for the nurse to take at this time?
A. Do nothing; this is a normal response
B. Strip the tubing to remove any clots
C. Place a clamp on the tube near the client's chest
D. Remove the collection chamber and connect the tubing to a new device
Correct answer:
The water seal of a chest tube acts as a one-way valve. Air bubbles in the water seal indicate a leak between the client and the chamber. The nurse should briefly clamp the tube near the client's chest to locate the source of the leak. Once identified, the nurse should unclamp the tubing and notify the physician immediately.
Choice A is incorrect because air bubbles in the water seal chamber are not a normal finding and indicate a leak. Choice B is incorrect as stripping the tubing could aggravate the issue and is not the initial appropriate action. Choice D is incorrect as it does not address the immediate need to locate and address the leak.
When a blood pressure cuff is too wide for a client's arm, what type of reading might this blood pressure cuff produce?
A. A normal reading
B. An abnormally low reading
C. An abnormally high reading
D. A fluctuating reading
Correct answer:
When a blood pressure cuff is too wide for a client's arm, it may produce an abnormally low blood pressure reading. This occurs because the oversized cuff can lead to an underestimation of blood pressure. It is essential to ensure that the cuff fits appropriately to obtain an accurate reading. An abnormally high reading (Choice C) is less likely with an oversized cuff, as it generally leads to lower readings. A normal reading (Choice A) is unlikely due to the inaccuracies caused by the oversized cuff. A fluctuating reading (Choice D) is not a typical result of using a cuff that is too wide; instead, it usually leads to consistently low readings.
Mr. G has been admitted to the hospital with a head injury after a 12-foot fall. Which of the following nursing interventions is most appropriate when monitoring intracranial pressure?
A. Administer hypotonic solutions
B. Keep the head of the bed elevated
C. Increase the client's core body temperature to 99.9 degrees
D. Administer corticosteroids as ordered
Correct answer:
Administering corticosteroids as ordered is appropriate when monitoring intracranial pressure in clients at risk of increased pressure to reduce brain tissue swelling. Elevating the head of the bed helps in managing intracranial pressure by promoting venous drainage. Administering hypertonic solutions is used to reduce brain edema and control intracranial pressure. Increasing the client's core body temperature is not recommended as it can exacerbate brain injury. Corticosteroids are not routinely used for all head injuries but may be indicated in specific cases, such as certain types of brain injuries where swelling needs to be controlled.
Which of the following conditions may warrant a serum creatinine level?
A. Rhabdomyolysis
B. Digitalis toxicity
C. Glomerulonephritis
D. All answers are correct
Correct answer:
A serum creatinine level may be warranted in conditions that can affect renal function or cause muscle breakdown. Rhabdomyolysis, characterized by muscle injury and breakdown, can lead to elevated creatinine levels due to the release of creatinine from muscles. Digitalis toxicity can impair renal function, leading to a need for monitoring creatinine levels. Glomerulonephritis, an inflammatory condition affecting the kidney's filtering units, can also impact renal function and require assessment of creatinine levels. Therefore, all the provided conditions may warrant a serum creatinine level to assess renal function and muscle breakdown.
A healthcare professional is preparing to insert an indwelling catheter in a female client. Which of the following positions of the client is most appropriate for this procedure?
A. Lithotomy position
B. Prone position
C. Dorsal recumbent position
D. High Fowler's position
Correct answer:
When preparing to insert an indwelling catheter for a female client, the most appropriate position is the dorsal recumbent position. In this position, the client lies on their back with knees bent. This position allows for easy access to the urethral area for catheter insertion. The lithotomy position, with legs elevated and spread apart, is more invasive and typically used for gynecological exams. The prone position, lying face down, is not suitable for catheter insertion. High Fowler's position, sitting upright at a 90-degree angle, is not ideal for catheter insertion as it does not provide proper access to the perineal area.
Which of the following conditions increases a client's risk of aspiration of stomach contents?
A. A client is in restraints
B. A client has a scaphoid abdomen
C. A client is lying prone
D. More than one answer is correct
Correct answer:
A client in restraints is at an increased risk of aspiration of stomach contents. When a client is restrained, they may be unable to effectively move or turn their body if they begin to vomit, which can lead to aspiration. This lack of mobility can hinder their ability to protect their airway. On the other hand, a scaphoid abdomen, which is sunken or hollowed, is not a direct risk factor for aspiration. Additionally, lying prone, facing downward, does not necessarily increase the risk of aspiration, as aspiration is more likely when lying supine (facing upward). Therefore, the correct answer is that a client is in restraints.
A client is preparing to undergo a cystoscopy for stones. Which of the following statements indicates that the client understands the procedure?
A. I better drink a lot of fluid now because I won't be able to after the test.
B. I will probably see a little blood when I urinate.
C. I will be able to go home after 3 days in the hospital.
D. I won't need any pain medicine; this probably will not hurt.
Correct answer:
The correct answer is, 'I will probably see a little blood when I urinate.' During a cystoscopy, a scope is inserted into the client's bladder to inspect structures or remove objects like stones. This procedure is usually performed under local or general anesthesia. It is common for clients to experience a small amount of blood in their urine (hematuria) or have pink-colored urine after the procedure. The other choices are incorrect because drinking a lot of fluid before the test, staying in the hospital for 3 days, and assuming no pain will be experienced are not accurate statements related to a cystoscopy procedure.
NCLEX-RN health promotion practice questions, set 2 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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The first five questions already include the rationale. Start full practice to unlock the remaining keys, missed-question review, and the rest of the bank.
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