NCLEX: health promotion
How long is the first phase of the transitional period of the newborn?
0-30 MINUTES
After instructing a 63-year old female with a new prescription for captopril (Capoten) for her hypertension, the nurse realizes the client needs further teaching when the client states
«I WILL USE A SALT SUBSTITUTE.»
The nurse is instructing a 53 year-old male client with newly-diagnosed type 2 diabetes how to care for his feet at home. Which statement indicates that the client understands?
«I'LL DRY MY FEET VERY WELL AFTER EVERY SHOWER.»
Following instruction about post-menopausal osteoporosis with a Caucasian 52-year old female, which statement indicates that the nurse should provide more education?
«I'M GLAD THAT I HAVE A LOW RISK OF GETTING OSTEOPOROSIS.»
During a routine check-up, the nurse assesses a 76-year old female whose husband died seven months ago. Which statement indicates ineffective coping?
«I'VE HAD NO INTEREST IN HOW I LOOK OR WHAT I WEAR. WHY BOTHER?»
An 18-year old male asks about using condoms to keep his girlfriend from becoming pregnant. What is the nurse's best response?
«IF YOU USE A SPERMICIDE WITH THE CONDOM, YOU'LL GET MORE PROTECTION.»
Two toddlers are arguing over a toy truck in the playroom. The nurse should say to the children
«LET'S SEE IF WE CAN FIND ANOTHER TRUCK, SO YOU EACH HAVE ONE TO PLAY WITH.»
A 17-year old girl and her mother are both in the exam room for the girl's school physical. Before asking the girl about her sexual history, which statement should the nurse make?
«MOTHER, I'M GOING TO ASK YOU STEP OUT, SO I CAN COMPLETE THE HEALTH HISTORY.»
After completing infertility evaluations, the husband is diagnosed with a low sperm count. When the nurse assesses his understanding of possible causes, the nurse knows more instruction is needed when the client says
«MY SCROTUM TEMPERATURE IS TOO COLD.»
A school nurse is performing annual scoliosis screenings. The nurse should assess students for all signs EXCEPT
BALANCED WAIST ANGLES.
A female client asks her healthcare provider about the benefits of receiving the human papillomavirus (HPV) vaccine. Which statement is the most appropriate response by the healthcare provider?
«THE HPV VACCINE CAN HELP PREVENT CERVICAL CANCER.»
A client who is 26 weeks pregnant arrives at the Emergency Department in full labor. She is admitted and gives birth to a live neonate. However, the baby's condition quickly deteriorates and death is imminent. The parents are Roman Catholics and request that their baby be baptized. What should the nurse do?
BAPTIZE THE NEONATE, REGARDLESS OF PERSONAL RELIGIOUS BELIEFS
The home health nurse is visiting a new client with COPD who has just been discharged from the hospital. What is the most important topic for the nurse to teach the client?
BETTER OXYGENATION AND LESS CO2 RETENTION
A client at 30 weeks gestation complains of heartburn. What is the best way for the nurse to explain it?
«THE STOMACH RELEASES A BACKFLOW INTO YOUR ESOPHAGUS.»
As vision changes with age, the ability to see colors can be altered. When the home health nurse helps an elderly client choose an outfit, which colors are most difficult for the client to distinguish?
BLUE AND GREEN
During her first prenatal appointment, a 24-year old primigravada asks the nurse how the doctor could tell she was pregnant "just by looking inside." The nurse explains that the client had a positive Chadwick's sign, which is a
BLUISH COLOR OF THE CERVIX AND VAGINAL WALLS.
A 26-year old client comes to the birthing center in early active labor. She is full-term and membranes are intact. The nurse locates fetal heart sounds above the client's umbilicus at midline. The nurse should continue to assess that the fetus is in which position?
BREECH
A mother calls the pediatric clinic to report that her 3-year old has diarrhea, and asks how to manage it at home. The nurse should suggest
CONTINUE THE CHILD'S USUAL DIET, AS TOLERATED.
On discharge from the hospital, the health care provider prescribes lisinopril (Prinvil, Zestril) for a 54-year old male client. Which common side effect should the nurse teach the client?
COUGH
A 7-month old infant weighing 16 pounds (7.25 kg) will have a normal urine output of
2 ML/KG/HR.
. A patient reports smoking 10 cigarettes per day for 40 years. How will the healthcare provider document this patient's smoking habit in terms of pack years?
20 PACK YEARS
. The nurse is instructing a client with newly-diagnosed type 2 diabetes how to use a blood glucose monitor. Which consistent glucose level should the client report to the health care provider?
250 MG/DL
At her 10-year old daughter's routine physical, a mother reports that her daughter has started to develop breasts and grow pubic hair. The nurse tells them that after signs of puberty appear, menstruation usually occurs within
30 MONTHS.
The nurse is doing discharge teaching for a client who is status-post total hip arthroplasty. The client should be instructed to do all of the following EXCEPT
APPLY CREAM TO THE INCISION EVERY DAY UNTIL SUTURES ARE REMOVED.
When meeting with a pregnant client to teach about prenatal nutrition, the nurse's FIRST step is to
ASK HER TO KEEP A FOOD JOURNAL UNTIL HER NEXT APPOINTMENT.
Before discharge after treatment for leg trauma, the nurse instructs the client on the tripod position when using crutches. Which is the proper distance for placement of the crutch tips?
6 INCHES TO THE FRONT AND SIDE OF THE TOES
A 41-year old male visits a urologist to learn about getting a vasectomy as a permanent method of contraception. Which statement should the nurse use during client education?
A 41-year old male visits a urologist to learn about getting a vasectomy as a permanent method of contraception. Which statement should the nurse use during client education?
Which chair is best for an elderly client who is learning self-care for managing hip pain from rheumatoid arthritis?
A STRAIGHT BACK CHAIR WITH A RAISED SEAT TO DECREASE FLEXION
The pediatric nurse is instructing the parents of a 10-year old boy who is newly diagnosed with type 1 diabetes. When teaching about hypoglycemia, which instruction should the nurse provide?
ALWAYS HAVE GLUCOSE TABLETS AND SUBCUTANEOUS GLUCAGON AVAILABLE
When the home health nurse reviews her daily schedule, which client is most at risk for abuse?
AN 84-YEAR OLD WOMAN WITH ADVANCED DIABETES COMPLICATIONS
The nurse is providing discharge instructions to the parents of a 7-year old girl who was admitted with a diagnosis of acute rheumatic fever. Which is a longterm care component for their daughter?
ANTIBIOTIC THERAPY
The cardiac nurse is teaching a client who has just been prescribed digoxin (Lanoxin). Which action will help prevent complications from the medication?
DAILY PULSE
The nurse notes that the apical heart rate of a neonate born 5 minutes ago is 152 and regular. What should the nurse do?
DOCUMENT AS A NORMAL HEART RATE
A 3-month old African American male is being assessed during his routine checkup. The nurse notes a dark blue pigmented mark across his back and buttocks. What should the nurse do?
DOCUMENT THE OBSERVATION IN THE INFANT'S RECORD
When examining the tympanic membrane of a toddler by otoscope, the nurse should move the child's pinna in which direction?
DOWN AND BACK
While planning a prenatal nutrition class for primigravid clients, the nurse knows to include the need for adequate Vitamin A. Which foods should the clients choose for their diets?
EGG YOLKS AND SQUASH
According to Erikson's stages of psychosocial development, which intervention is most appropriate for a hospitalized 16-year old?
ENCOURAGE FRIENDS TO VISIT AT THE HOSPITAL
A primigravid client who is at 14 weeks gestation has been diagnosed with hyperemesis gravidarum. The nurse explains to the client that the condition is related to high levels of
ESTROGEN.
To assess cranial nerve VII, the nurse should ask the client to all of the following actions EXCEPT
EXTEND THE TONGUE.
When a child is able to grasp the idea that a ball continues to exist, even though the parent places the ball under a pillow, which of Piaget stages is the child in?
SENSORIMOTOR
When her pregnancy is confirmed, a 28-year old becomes worried about being physically uncomfortable. She tells the nurse, "I'm not sure I want to be pregnant." What does the nurse understand about the client's statement?
SHE IS EXPERIENCING AMBIVALENCE ABOUT BEING PREGNANT
When teaching a client who is planning to get pregnant about the need to increase folic acid, which food can the nurse suggest?
SPINACH
A 32-year old client refuses to have any analgesia or anesthesia during her birth experience. As the nurse assists her during the second stage of her labor, which position should she use to begin pushing?
SQUATTING WITH HER BODY CURVED INTO A «C» POSITION
Following the birth of her first child, a 27-year old makes an appointment to discuss oral contraception. During the assessment, the client discloses a family history of heart disease. What question should the nurse ask next?
«ARE YOU A SMOKER?»
A school nurse is instructing a health class about the dangers of smoking. Which student's statement shows a lack of understanding and need for more information?
«CHEWING TOBACCO IS SAFE SINCE THERE'S NO SMOKE.»
As the nurse assesses a new client who is being evaluated for Hepatitis C, which question should the nurse ask?
«HAVE YOU EVER GOTTEN A TATTOO?»
The nurse is instructing a 46-year old primigravid client prior to a percutaneous umbilical blood sampling (PUBS) procedure. When the client asks why, the nurse explains that it will diagnose
GENETIC DISORDERS.
A mother tells the nurse that her 8-year old doesn't eat as much as her toddler or teenager. The nurse should explain that school-age children have a lower
GROWTH RATE.
The healthcare provider is teaching a patient with emphysema pursed-lip breathing. Pursed lip breathing helps patients with emphysema because it
HELPS KEEP THE SMALL AIRWAYS OPEN AND PREVENTS AIR TRAPPING.
. The nurse plans to instruct parents of a 4-year old with cystic fibrosis (CF) about the child's nutritional needs. Which should be included during teaching?
HIGH CALORIE
A client calls the clinic after a home pregnancy test is positive. Which hormone will be cause this result?
HUMAN CHORIONIC GONADOTROPIN
All the following affect pharmacokinetics in the elderly EXCEPT
IMPROVED BLOOD-BRAIN BARRIER.
During a routine prenatal appointment, a client who is six months pregnant states she has constipation. To relieve this condition, the nurse should instruct her to
INCREASE FLUID INTAKE TO 3 LITERS EACH DAY
A 79-year old home health client with severe arthritis of the hands tells the nurse that she has difficulty instilling eye drops for glaucoma. What can the nurse plan to assist the client?
INSTRUCT THE CLIENT TO LIE DOWN WHEN USING THE DROPS
The nurse is teaching a new hemodialysis client how to monitor fluid status between dialysis treatments. Which action is most important for the client to record daily?
INTAKE, OUTPUT, WEIGHT
During a routine check-up for her 2-year old son, the mother proudly tells the nurse, "He loves to drink milk! I give him as much as he wants." The nurse should counsel the mother and tell her that more than 3.5 cups a day can lead to
IRON DEFICIENCY.
The mother of a 2-year old girl is frustrated by her daughter's temper tantrums, and asks the pediatric nurse for advice. Which action is most appropriate when a tantrum occurs?
LEAVE HER ALONE, AS LONG AS SHE IS SAFE
As the nurse prepares to instruct a client who has just been prescribed atorvastatin (Lipitor), which periodic laboratory test should the client receive?
LIVER FUNCTION STUDIES
The nurse reviews recent lab results with a new client. Which elevated test level is most important for the nurse to address in order to reduce the risk for coronary artery disease (CAD)?
LOW-DENSITY LIPOPROTEIN
A 32-year old primigravida who 35 weeks pregnant is admitted following a rupture of membranes and loss of mucous plug 9 hours earlier. An internal exam shows she is dilated 4 cm. Since she is at risk for infection, which action is most appropriate?
MONITOR HER TEMPERATURE FREQUENTLY
A patient with pre-eclampsia is admitted to the unit with an order for magnesium sulfate. The nurse will understand that the therapy is effective if
NO SEIZURES OCCUR
At her first prenatal appointment, the client states that her last menstrual period began on February 5, 2017 and ended on February 10, 2017. Using Naegele's rule her estimated date of birth would be
NOVEMBER 12, 2017.
Management of gestational diabetes mellitus (GDM) is usually done with
NUTRITIONAL THERAPY
During her check-up after a spontaneous abortion at 12 weeks, a client becomes angry and screams at the nurse, "Why did God punish me? I haven't done anything to deserve this." Which response is most appropriate?
«I CAN SEE THAT YOU'RE ANGRY. IT'S SO HARD TO LOSE YOUR BABY.»
Which common pregnancy condition can occur during the 3rd trimester?
PHYSIOLOGIC ANEMIA
At her six-week postpartum appointment, the client tells the nurse that she wants to resume oral contraception as soon as possible. Because the client is breast-feeding, the nurse knows that the best option is
PROGESTIN.
When a client with mid-stage Alzheimer's disease becomes agitated, which intervention should the nurse use?
PUTTING AN ARM AROUND THE CLIENT'S WAIST
When a father calls Poison Control Center after discovering that his 3-year old son has taken 12 grape-flavored chewable acetaminophen tablets, what should the nurse instruct the father to do?
QUICKLY GO TO THE EMERGENCY DEPARTMENT
When instructing a client with acquired immunodeficiency syndrome (AIDS) about proper food choices, which item should the nurse teach the client avoid?
RAW SHELLED OYSTERS
Assessment of a primigravida in active labor reveals cervical dilation at 9 cm, 100% effacement, and the fetus at +1 station. When the medical resident orders meperidine 50mg IM for the patient, what should the nurse do?
REFUSE TO ADMINISTER THE MEDICATION TO THE PATIENT
Percussion is a physical assessment technique used to assess all the following EXCEPT
RESILIENCE OF BODY TISSUES
Rhogam is most often used to treat____ mothers that have a ____ infant.
RH NEGATIVE, RH POSITIVE
he football coach invites the school nurse to instruct the team on proper hydration during hot weather. The nurse teaches the athletes to avoid dehydration by
TAKING A FLUID BREAK EVERY 30 MINUTES DURING PRACTICE.
The most appropriate toys to give to a 5-month old infant are
TEETHING OBJECTS.
When a mother enters the playroom of the pediatrics unit to visit her 3-year old son, he does not immediately go to her. A reason for his behavior is
THE CHILD IS DISPLAYING NORMAL BEHAVIOR.
After the nurse does an assessment of an 83-year old with dementia, what will be the most realistic plan of care for the client?
THE CLIENT CAN BE SUPPORTED TO FUNCTION AT THE BEST POSSIBLE LEVEL OF AUTONOMY
A 27-year old woman has Type 1 Diabetes (T1D). She and her husband want to have a baby. Her endocrinologist gave them information on pregnancy and diabetes. The first thing the nurse should discuss with the prospective parents is
THE NEED FOR EARLY PRENATAL MEDICAL OVERSIGHT.
A client with type 2 diabetes has a glycosylated hemoglobin (HbA1c) level of 9.1%. The nurse will need to make an instruction plan because this lab result indicates
THE NURSE MUST MAKE A PLAN TO HELP THE CLIENT MANAGE POOR GLUCOSE LEVEL CONTROL.
Which developmental age group is most likely to regress when ill?
TODDLER
When caring for an older adult, the nurse may see an increase in
URINARY RETENTION.
What is the best way to educate a 10-year old girl about her upcoming heart surgery?
USE A MODEL OF THE HEART TO SHOW HER HOW THE SURGERY WILL GO
When making a checklist for an older adult who is learning to do self-catherization, which action is most helpful?
USE SHORT WORDS AND SENTENCES
During a home assessment of a 2-year old, which behavior indicates normal development?
USES A CUP TO DRINK
A 19-year old college student comes to the clinic after missing her second period. When a pregnancy is confirmed, she asks about having an abortion within the next few weeks. The nurse tells her that an abortion can safely be done by which method?
VACUUM ASPIRATION
The nurse is teaching parents to administer eardrops at home. Which action will indicate that the parents understand?
WATCH AS THEY ADMINISTER THE EARDROPS
When planning to teach a patient with a new colostomy, which food should the nurse recommend to avoid odors in the stool?
YOGURT
A 13-year old has just started to menstruate. Which statement should the nurse use during client education?
YOU CAN TAKE A MILD ANALGESIC IF YOU GET CRAMPS.»
