Health Promotion and Maintenance NCLEX RN Review Questions Answers and Rationale

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1.    C. When irrigating a colostomy, the patient should insert the catheter 2” to 4” into the stoma. Inserting it less than 2” may cause leakage. Inserting it more than 4” may cause trauma to the intestinal mucosa.

2.    D. When administering several oral medications, the nurse should state the name of each medication and its action or use before administering it. The patient may take the medications all at once at a time with any amount or type of fluid. Leaving medications at the bedside may lead to errors, such as the patient not taking them. The nurse should always observe the patient taking medication to ensure that it has been given.

3.    B.The nurse should report the information to the doctor because the patient’s safety may be endangered. The fact that the patient has received the drug for several days does not guarantee that giving another dose is safe. Filing an incident report and finding out if there are extenuating reasons for giving the drug would not address patient safety.

4.    D. The nurse should instruct the patient to remain supine for the time specified by the doctor. Local anesthetics used in a subarachnoid block do not alter the gag reflex. No interactions between local anesthetics and food occur. Local anesthetics do not cause hematuria.

5.    B. When changing a female neonate’s diaper, the caregiver should clean the perineal area form front to back to prevent infection, and then dry the area thoroughly to minimize skin breakdown. For a male, the caregiver should clean and dry under and around the scrotum. Because of anatomic factors, a female’s diaper should have the double thickness toward the back. The diaper, not the neonate, should be positioned properly.

6.    C. Dopamine activates dopaminergic receptor sites only at low doses. At normal or high doses, dopamine activates alpha and beta1 receptor sites. Dopamine does not activate beta2 receptor site.

7.    C. In early childbirth education classes, instruction on the physiological aspects of pregnancy may include warning signs of complications, the anatomy and physiology of pregnancy, nutrition, and fetal development.

8.    C. When applying a topical agent, the nurse should begin at the midline and use long even, outward, and downward strokes in the direction of hair growth. This application patterns reduces the risk of follicle irritation and skin inflammation.

9.    A. Ingesting 500 mg or more of caffeine can significantly alter the anxiolytic effects of lorazepam. Other dietary restrictions are unnecessary. Staying out of the sun or using sunscreens is required when taking phenothiazines. An adequate salt intake is necessary for patients receiving lithium.

10.    B. To prevent reflux of stomach acid into the esophagus, the nurse should advise the patient to avoid foods and beverages that increase stomach acids, such as coffee and alcohol. The nurse also should teach the patient to avoid lying down after meals, which can aggravate reflux, and to take antacids after eating. The patient need not limit fluid intake with meals as long as the fluids are not gastric irritants.

11.    B. A client who’s predisposed to preterm labor should abstain from sexual intercourse unless she uses a condom because semen contains prostaglandins that stimulate uterine contractions. A client receiving ritodrine should return to the clinic in 1 to 2 weeks for a regular checkup and evaluation for preterm labor. Returning to work — especially to a job that involves much standing — is contraindicated immediately after preterm labor. Ritodrine must be taken regularly to prevent recurrence of preterm labor.

12.    C. Dorothea Orem’s general theory of nursing addresses self-care deficits as the basis for nursing care. This theory posits that the nurse intervenes to reestablish the client’s self-care capacity. Dorothy Johnson’s behavioral systems theory views nursing as a means to reestablish balance in the client’s behavioral subsystems, which have been disrupted by stress. According to Virginia Henderson’s theory of nursing, the nurse focuses on the client’s basic needs. In Martha Rogers’ unitary human beings theory, the nurse helps the client balance the changes that occur as the client constantly evolves.

13.    D. PTH increases the serum calcium level and decreases the serum phosphate level. PTH doesn’t affect sodium, potassium, or magnesium regulation.

14.    B. Prolonged eye irrigation after a chemical burn is the most effective way to prevent formation of permanent scar tissue and thus help prevent vision loss. After a potentially serious eye injury, the victim always should seek medical care. Eye irrigation isn’t considered primarily a stopgap measure.

15.    B. Coping is the process by which a person deals with problems using cognitive and noncognitive components. Cognitive responses come from learned skills; noncognitive responses are automatic and focus on relieving discomfort. Age could have either a positive or negative effect during crisis, depending on previous experiences. Previous coping skills are cognitive and include the thought and learning necessary to identify the source of stress in a crisis situation.

16.    C. A blood return or a lack thereof isn’t always an indicator of infiltration, especially in infants and small children, whose veins are small and fragile. Erythema, pain, edema at the site or around it, blanching, and streaking are signs of infiltration. The infusion should be discontinued immediately if any of these signs are observed.

17.    B. A low-fat diet (one that maintains weight within 20% of recommended body weight) has been found to decrease a woman’s risk of breast cancer. A baseline mammogram should be done between ages 30 and 40. Monthly breast self-examinations should be done between days 7 and 10 of the menstrual cycle. The client should continue to perform monthly breast self-examinations even when receiving yearly mammograms.

18.    C. Made of elastic material, antiembolism stockings are designed to reduce or prevent edema of the legs or feet by promoting venous return. They do this by increasing — not decreasing — arterial and venous blood circulation to the legs and feet. They don’t maintain warmth in the legs; however, blankets can be used for this purpose

19.    B. The American Cancer Society has recently adopted the recommendation that all women over age 40 have annual mammograms. Decisions about mammography for women in all other age categories and circumstances are made by the physician and the client.

20.    D. Allowing the parents to stay and participate in the child’s care can provide support to both the parents and the child. The other interventions won’t address the client’s diagnosis and may exacerbate the problem.

21.    D. Levothyroxine is the agent of choice for thyroid hormone replacement therapy because its standard hormone content gives it predictable results. Methimazole is an antithyroid medication used to treat hyperthyroidism. Thyroid USP desiccated and liothyronine are no longer used for thyroid hormone replacement therapy because they may cause fluctuating plasma drug levels, increasing the risk of adverse effects.

22.    D. When giving an I.M. injection, the nurse inserts the needle into the muscle at a 90-degree angle, using a quick, dartlike motion. A 15-degree angle is appropriate when administering an intradermal injection. A 30-degree angle isn’t used for any type of injection. A 45- or 90-degree angle can be used when giving a subcutaneous injection.

23.    C. Tolazamide has a slower onset of action than other sulfonylureas.

24.    A. Tensing the buttocks before sitting or rising may ease edema, ecchymosis, or other discomfort caused by perineal sutures; the client should maintain the tension briefly. Supporting body weight on the arms of a chair strains the client’s arms and prevents her from assuming a full, comfortable sitting position. Placing a pillow behind her back may cause her to lean forward, putting even more pressure on the perineum. Sitting on an inflatable ring relieves pressure on some areas of the perineum but places more pressure on others.

25.    C. Notifying the surgeon takes priority because informed consent must be obtained before the client receives drugs that can alter cognition. Giving the preoperative analgesic at the scheduled time would alter the client’s ability to give informed consent. Obtaining consent to surgery isn’t within the scope of nursing practice, although the nurse may confirm or witness consent. Canceling surgery also isn’t within the scope of nursing practice.

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