(ANSWERS & RATIONALE) Health Promotion and Maintenance NCLEX RN Review

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1. C. Celiac disease is caused by an intolerance to gluten, which is a protein found in wheat, oats, barley and rye, All the foods in option 3 contain gluten. Option 1 would be eliminated if the child had a lactose intolerance, option 4 would be eliminated if the child had a fat intolerance.

2. D. The most important assessment is vital signs for hemorrhage. The nurse will also check the fundus and for lochia, but the most important is for hemorrhage because it is the most common cause of death in the first hour after delivery.

3. D. Unless the antibiotic is safe for the infant, it is best not to feed the baby, but in order to continue establishment of milk flow, the breasts must be stimulated.

4. A. Exercise, specifically dorsiflexion of the feet, prevents stasis by promoting venous valve and muscle action. Early ambulation, deep breathing and elevating the foot of the bed all increase blood flow. If DVT develops, the client will be placed on bedrest.

5. B. Alzheimer’s disease is a progressive disease that takes years until the patient is completely incapacitated. It is best to support the individuals self esteem by helping them maintain as much control of their life through independent functioning of self care and activities of daily living.

6. C. The physician should be notified immediately. A suspected Wilms’ tumor should never be palpated more than necessary because of the potential for metastasis and should be treated immediately following discovery. It is really not a nursing responsibility to assess for lymph node enlargement.

7. D. Patients with renal failure should have a diet that provides (high biologic value) proteins rich foods such as eggs, dairy products and meats. These are necessary to maintain a positive nitrogen balance. Foods high in calories are also necessary, and sodium intake should be limited. Foods high in Potassium should be AVOIDED due to decreased ability of the kidney(s) to filter and excrete Potassium.

8. B. The function of the lens is that of accommodation, the focusing of near objects on the retina by the lens; therefore, only the remaining lens will function in this capacity, depending on whether a cataract is present.

9. A. Although abstinence is still the best protection against spread of the HIV virus, the use of a latex condom with a H20 soluble lubricant is the most effective means. All other choices given have no proven validity against the spread of the HIV Virus.

10. B. If the bladder is full, it will push the uterus up out of the pelvis above the umbilicus. The uterus will not contract sufficiently, which could lead to increased bleeding.

11. B. Children with cardiac disease have lowered resistance to upper respiratory infections and should avoid any circumstances that may expose them to even mild infections. Option 1 is unrealistic and option 3 would not put the child at risk since allergies are not contagious, option 4 is wrong because children with cardiac conditions do receive routine immunizations.

12. D. Elevation of the legs promotes circulation and prevents venous stasis and more clot formation. Nursing measures aim at preventing further thrombi from forming and the already present thrombus from detaching. Elastic hose (2) are necessary when the client is up walking again. Placing a pillow under the limb (1) could cause a bend at the groin, with resulting decreased circulation. The client must be kept on bedrest until the danger of emboli passes (4 to 7 days).

13. A. One of the more common problems following Gastric surgery is Dumping Syndrome. Dietary management is the key to reduce or prevent this potential problem from developing. The diet should contain moderate amounts of fat, as well as below in carbohydrates, especially small molecular carbohydrates such as sucrose and glucose. These dietary modifications will result in decreased hypertonicity of the intestinal contents, and prevent osmotic pull of extracellular fluid into the intestinal area, lessening the possibility for Dumping Syndrome to develop.

14. B. While regulating or even touching an IV is definitely not within the scope of behaviors that an NA can legally perform (1), both teaching and clarification of duties is needed in this situation. Before accusing the NA, a nonpunitive environment should be created so teaching of both the LVN and NA can occur, and this action will not happen again. Unless too much medication was given, an incident report does not need to be filled out (2). Confronting the team members in a staff meeting (3) would not be following good management principles.

15. D. Following Total Gastrectomy the production of Intrinsic Factor is permanently destroyed. This is necessary (Intrinsic Factor) for the absorption of Vitamin B12 from the GI tract. As a result patients MUST receive Vitamin B12 by parenteral route throughout life, or a condition known as Pernicious Anemia will develop, and can prove to be fatal. Regular IM injections on a monthly basis of 100-200ug is the usual therapeutic dose.

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