Health Promotion and Maintenance NCLEX RN Review

1. A 4 year old with Celiac Disease is in the hospital with an exacerbation of Celiac Crisis due to improper dietary intake. When teaching the mother the dietary restrictions for her child, which of the following foods must be completely eliminated from the child’s diet?

a. Whole milk, ice cream and cheese
b. Rice, corn and soybeans
c. Bread, oatmeal and pretzels
d. Beef, liver and veal

2. Following delivery of a normal newborn, the nurse will assess the mother every 15 minutes for the first hour. The most important assessment is for

a. Placental fragments.
b. Presence of lochia.
c. Condition of the fundus.
d. Hemorrhage.

3. A breast feeding mother develops mastitis in the left breast and is put on an antibiotic for seven days. She asks the nurse if she can continue breast feeding. The nurse’s best answer would be:

a. “Only breast feed from the right breast.”
b. “Do not breast feed or stimulate the breasts until the infection is resolved.”
c. “Continue breast feeding, this is not a contraindication.”
d. “Pump the breasts and discard the milk until the infection resolves.“

4. The nurse is assigned a client at risk for developing deep vein thrombosis (DVT) following a total knee replacement. The most effective measure to prevent this complication is

a. An exercise schedule of dorsiflexion of the feet.
b. Maintaining a flat bed from the waist down.
c. Instruction in shallow breathing techniques.
d. Maintaining the client on bedrest.

5. An elderly man is admitted to the Geriatric Unit for his forgetfulness and severe behavioral changes. He is diagnosed with Alzheimer’s Disease. Which of the following should be the primary goal of nursing intervention?

a. Keep him away from problems of daily living
b. Keep his capacity for self care activities to the optimum
c. Keep him isolated
d. Keep all available resources to increase his dependency

6. While bathing a 1 year old, the nurse feels a large mass in the abdominal area and notices that his diaper is soiled with pinkish-tinged urine. The initial nursing action is to

a. Gently palpate the abdominal mass to determine if it is a Wilms’ tumor.
b. Continue the assessment by observing his behavior indicating pain on palpation.
c. Immediately notify the physician.
d. Assess if the tumor has spread to the lymph nodes.

7. Which of the following is an INCORRECT statement regarding diet therapy for a patient in renal failure?

a. Limit dietary protein
b. Provide a diet high in carbohydrates
c. Limit Sodium (NA) intake
d. Provide a diet high in Potassium rich food

8. Instructions given to clients following cataract surgery include the information that

a. Contact lenses will be fitted before discharge from the hospital.
b. They must use only one eye at a time to prevent double vision.
c. They will be able to judge distances without difficulty.
d. The eye patch will be removed in 3 to 4 days, and the eye may be used without difficulty.

9. In teaching High School students about health practices that promote the prevention of spread of the HIV virus, the nurse should include which of the following:

a. Use a latex condom and water soluble lubricant during intercourse
b. Abstain from intercourse if the female is menstruating
c. Following oral intercourse, use an over-the-counter mouthwash so to destroy the HIV virus
d. Shower immediately with an antibacterial soap after intercourse, so to destroy the HIV virus

10. Following delivery of a healthy baby, the nurse completes a postpartum assessment of the new mother. Which of the following symptoms would be indicative of a full bladder?

a. Pulse 52 beats/min.
b. Fundus 2F above umbilicus.
c. Increased uterine contractions.
d. Decreased lochia.

11. The parents of a child with Tetralogy of Fallot have been given discharge instructions. Which of the following situations would the parents be instructed to avoid?

a. All infant contact with persons outside the home
b. Infant contact with persons who have mild colds
c. Infant contact with persons who have severe allergies
d. Routine immunizations

12. A nursing measure to prevent the complication of deep vein thrombophlebitis following surgery would include

a. Wearing elastic hose at all times.
b. Having the client sit up TID.
c. Placing pillows under the affected limb
d. Elevating the foot of the bed.

13. Following Gastric Resection, patients are prone to developing Dumping Syndrome. Which of the following types of dietary intake by the patient would be MOST helpful to either reduce or prevent this syndrome from developing?

a. Moderate fat, low carbohydrate
b. High fat, high carbohydrate
c. Low fat, low carbohydrate
d. Moderate fat, high carbohydrate

14. The RN observes the nursing assistant (NA) regulating the IV of an oncology client receiving morphine sulfate for pain. An LVN on the RN’s team is responsible for the client and has assigned the client to the NA. The RN’s intervention is to

a. Immediately inform the charge nurse and fill out an incident report.
b. Ask the LVN and the NA to meet with the RN to discuss the responsibility -parameters each of them has.
c. Inform the LVN so that he/she intervenes to instruct the NA that this -action is not within the realm of responsibility of an NA.
d. Call a staff meeting and confront the LVN and the NA.

15. Following Total Gastrectomy patients will require vitamin replacement. Of the following, which vitamin is ESSENTIAL and MUST be given throughout life:

a. Vitamin C
b. Vitamin B6
c. Vitamin D
d. Vitamin B12

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