NCLEX-RN health promotion practice questions, set 3
NCLEX-RN · health promotion
NCLEX-RN 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-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 nurse is caring for an 83-year-old man who has had swallowing difficulties. All of the following interventions are appropriate for this client EXCEPT:
A. Keep the client in an upright position at all times
B. Auscultate lung sounds every shift and after feedings
C. Maintain suction equipment at the client's bedside
D. Instruct the client about how to perform swallowing exercises
Show answer and rationale
Correct answer: A — Keep the client in an upright position at all times
When caring for a client with swallowing difficulties, it is crucial to prevent aspiration of food into the lungs. Appropriate interventions include auscultating lung sounds every shift and after feedings to assess for any changes in breathing patterns, maintaining suction equipment at the client's bedside in case of difficulties, and providing instruction on swallowing exercises. Keeping the client in an upright position at all times is not necessary and may not always be feasible or comfortable for the client. This rigid requirement is not part of the standard care protocol for managing swallowing difficulties.
Question 2
A healthcare professional is preparing to draw a blood specimen from an adult client's central line. All of the following actions for this procedure are correct EXCEPT:
A. Disconnect the current infusion
B. Clean the cap with alcohol and attach a 5 cc syringe
C. Draw 5 cc of a blood sample to discard
D. Flush with saline after the sample
Show answer and rationale
Correct answer: B — Clean the cap with alcohol and attach a 5 cc syringe
When drawing a blood specimen from a central line, the healthcare professional should disconnect any infusions that are currently running and that could contaminate the specimen. It is important to use a minimum size of a 10 cc syringe when using a central line to avoid placing too much pressure on the catheter. Cleaning the cap with alcohol and attaching a 5 cc syringe is not appropriate as a larger syringe size should be used for this procedure. Drawing 5 cc of a blood sample to discard and flushing with saline after the sample are correct steps in the process of drawing a blood specimen from a central line.
Question 3
Mrs. O is seen for follow-up after an episode of acute pancreatitis. Her physician orders a serum amylase level and the result is 200 U/L. Which of the following is a potential cause of this result?
A. The client is pregnant
B. The client has hypertension
C. The client is in renal failure
D. The client has pancreatitis
Show answer and rationale
Correct answer: D — The client has pancreatitis
An elevated serum amylase level after pancreatitis may indicate another attack of the condition. It is common to order serum amylase as part of routine follow-up after pancreatitis. Elevated levels can also be seen in related gastrointestinal conditions like cholecystitis or an intestinal blockage. Therefore, in this case, the most likely cause of the elevated serum amylase level is a recurrence or ongoing pancreatitis. The other options, including pregnancy, hypertension, and renal failure, are not typically associated with an elevated serum amylase level in the context of follow-up after acute pancreatitis.
Question 4
The OR nursing staff are preparing a client for a surgical procedure. The anesthesiologist has given the client medications, and the client has entered the induction stage of anesthesia. The nursing staff can expect which of the following symptoms and activities from the client during this time?
A. Irregular breathing patterns
B. Minimal heartbeat, dilated pupils
C. Relaxed muscles, regular breathing, constricted pupils
D. Euphoria, drowsiness, dizziness
Show answer and rationale
Correct answer: D — Euphoria, drowsiness, dizziness
During the induction stage of anesthesia, the client may exhibit symptoms like euphoria, drowsiness, or dizziness. This stage occurs after the administration of medications by the anesthesiologist and ends when the client loses consciousness. Choice A is incorrect as irregular breathing patterns are not typically associated with the induction stage. Choice B is incorrect as minimal heartbeat and dilated pupils are not commonly observed during this stage. Choice C is incorrect as relaxed muscles, regular breathing, and constricted pupils are not indicative of the induction stage of anesthesia.
Question 5
A client returns from surgery after having a colon resection. The nurse is performing an assessment and notes the wound edges have separated. This condition is called:
A. Evisceration
B. Hematoma
C. Dehiscence
D. Granulation
Show answer and rationale
Correct answer: C — Dehiscence
Wound dehiscence occurs when the edges of a wound pull apart. The condition may occur following a surgical procedure if the sutures were deficient. Wound dehiscence may also occur following a wound infection or in cases where a client significantly stretches or overuses the associated tissues. Evisceration refers to the protrusion of internal organs through an open wound. Hematoma is a localized collection of blood outside the blood vessels. Granulation is the formation of new connective tissue and tiny blood vessels on the surface of a wound during the healing process.
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Question 6
Which of the following situations warrants a measurement for orthostatic hypotension?
A. A 36-year-old male with a spinal injury
B. An 86-year-old female with significantly altered mental status
C. A 58-year-old female with near-syncope
D. A 41-year-old male with acute deep vein thrombosis
Correct answer:
The correct answer is a 58-year-old female with near-syncope. Orthostatic hypotension is a drop in blood pressure of greater than 20 mmHg systolic when moving from a sitting or lying position to standing. Patients at higher risk include those with syncope or near-syncope, symptomatic hypovolemia, and those prone to falls. The other choices are less likely to present with orthostatic hypotension. A spinal injury, altered mental status, and acute deep vein thrombosis are not directly associated with the immediate need for orthostatic hypotension measurement.
A client has been administered ketamine by a physician in preparation for general anesthesia. Which of the following side effects should the nurse monitor for in this client?
A. Delirium
B. Muscle rigidity
C. Hypotension
D. Pinpoint rash
Correct answer:
Ketamine is an anesthetic that induces dissociation and lack of awareness in a client. It can be used before general anesthesia or during short procedures for sedation. Ketamine may lead to side effects such as delirium, hallucinations, hypertension, and respiratory depression. Therefore, the nurse should monitor the client for delirium, as it is a potential side effect associated with ketamine use. Muscle rigidity, hypotension, and pinpoint rash are not typically attributed to ketamine administration and are less likely to occur in this scenario.
A client is being monitored for decreased tissue perfusion and increased risk of skin breakdown. Which measure best improves tissue perfusion in this client?
A. Massaging the reddened areas
B. Performing range of motion exercises
C. Administering antithrombotics as ordered
D. Feeding the client a high-carbohydrate diet
Correct answer:
For a client at risk of impaired skin integrity due to decreased tissue perfusion, improving mobility is crucial to enhance tissue perfusion and prevent skin breakdown. Range of motion exercises are beneficial to increase circulation and prevent complications. Massaging reddened areas may further damage fragile skin. Administering antithrombotics may be necessary for specific conditions but does not directly address tissue perfusion. Feeding a high-carbohydrate diet does not directly improve tissue perfusion in this context.
Which of the following situations might warrant a laboratory magnesium level?
A. Hyperthyroidism
B. Arthritis
C. Ulcerative colitis
D. Depression
Correct answer:
Ulcerative colitis can lead to symptoms such as abdominal pain, fever, diarrhea, and weight loss. This condition may impact the absorption of certain nutrients, including magnesium. Therefore, patients with chronic gastrointestinal conditions like ulcerative colitis should be screened for electrolyte imbalances related to impaired digestion. Hyperthyroidism, arthritis, and depression do not typically directly affect magnesium levels in the same way as gastrointestinal conditions like ulcerative colitis.
A 58-year-old client is being tested for rheumatoid arthritis. Her physician orders an erythrocyte sedimentation rate (ESR). Which of the following results is most likely to be associated with arthritis?
A. 5 mm/hr
B. 12 mm/hr
C. 28 mm/hr
D. 40 mm/hr
Correct answer:
The erythrocyte sedimentation rate (ESR) measures levels of inflammation in the body. Elevated ESR levels are commonly seen in autoimmune conditions like rheumatoid arthritis due to the presence of inflammation. In women over 50 years old, a normal ESR is typically below 30 mm/hr. Therefore, a result of 40 mm/hr is more indicative of arthritis in a 58-year-old individual. Choices A, B, and C are below the normal ESR range for a woman of this age and would not be as strongly associated with arthritis.
A client with adrenal insufficiency has a potassium level of 7.2 mEq/L. Which of the following signs or symptoms might the client exhibit with this result?
A. Peaked T waves on the ECG
B. Muscle spasms
C. Constipation
D. A prominent U wave on the ECG
Correct answer:
A client with hyperkalemia may exhibit peaked T waves on an electrocardiogram. This manifestation is an early sign of high potassium levels, but diagnosis should not be based on this aspect alone. Untreated, hyperkalemia can lead to progressively worsening cardiac instability. Muscle spasms (Choice B) are more commonly associated with hypocalcemia. Constipation (Choice C) is not a typical sign of hyperkalemia. A prominent U wave on the ECG (Choice D) is associated with hypokalemia, not hyperkalemia.
While caring for a client who has just come from surgery and is in the recovery room with an endotracheal tube in place, the nurse deflates the cuff on the tube and removes it. The client sits up in bed, grasps his throat, and begins to make wheezing sounds. Which of the following conditions is the most likely cause of this situation?
A. The client is choking on part of the tube
B. The client has anxiety
C. The client is having a laryngospasm
D. The client is having a normal response from anesthesia
Correct answer:
After surgery, some clients may experience a laryngospasm during emergence from anesthesia. A laryngospasm can lead to the closure of the laryngeal opening due to spasm of the vocal cords. In this scenario, the client's symptoms of wheezing and throat grasping are indicative of a laryngospasm rather than choking on the tube, anxiety, or a normal response from anesthesia. The nurse should act promptly to open the airway to aid breathing and consider administering muscle relaxants as necessary.
A nurse is caring for a 3-day old infant who needs an exchange
transfusion. Which of the following statements is appropriate for
teaching the child's parents about this procedure?
A. The registered nurse will be performing the procedure
B. The procedure takes approximately 1 ? hours.
C. The nurse will draw out 250cc of blood and then immediately replace
it with 250cc
D. The infant will continue to receive phototherapy during the
procedure.
Correct answer:
: An exchange transfusion is a method of controlling high
bilirubin levels in infants when traditional phototherapy is
unsuccessful. During an exchange transfusion, the physician removes
5-10 cc of blood and then replaces it with donor blood. The parents of
this infant should know that the procedure is always performed by a
physician and will take approximately 1 ½ hours to complete.
A nurse is assisting a pregnant client who is having an amniocentesis.
Which of the following statements by the nurse indicates the correct
teaching for this procedure?
A. I'm going to help you lie lat on your back for this."
B. Don't worry, I'm sure everything will be all right."
C. I will need to help you remove your shirt for this procedure."
D. Now that the procedure is inished, I will put a small bandage over the puncture site."
Correct answer:
An amniocentesis is performed to draw amniotic luid
from the sac around the fetus during pregnancy. It may be analyzed for
certain disorders or complications associated with pregnancy.
Following the procedure, the nurse should wash the client's abdomen
and place a small bandage over the puncture site
A client has started sweating profusely due to intense heat. His overall
luid volume is low and he has developed electrolyte imbalance. This
client is most likely suffering from:
A. Malignant hyperthermia
B. Heat exhaustion
C. Heat stroke
D. Heat cramps
Correct answer:
Heat exhaustion occurs when a person has enough
diaphoresis that he becomes dehydrated. Intense sweating can cause
both luid and electrolyte imbalances. Untreated heat exhaustion can
lead to heat stroke, which results in organ damage, loss of
consciousness, or death.
NCLEX-RN 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-RN exam guide.
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.
Keep going past these 15 questions
Missed-question review, longer banks, and the rest of 20,000+ nursing practice questions open when you start studying.
