NCLEX Practice Exam Health Promotion and Maintenance with Answers and Rationale

1. Today in Jezza’s class, they are discussing about the cranial nerves. What equipment would be necessary to complete an evaluation of cranial nerves 9 and 10 during a physical assessment?

a. A cotton ball

b. A penlight

c. An ophthalmoscope

d. A tongue depressor and flashlight


2. Lita, a student nurse is currently assigned at the Medical ward. While accompanying the staff nurse in charge, she has learned that the patient has state IV tumor. Which technique would be best in caring for a client following receiving a diagnosis of a state IV tumor in the brain?

a. Offering the client pamphlets on support groups for brain cancer

b. Asking the client if there is anything he or his family needs

c. Reminding the client that advances in technology are occurring everyday

d. Providing accurate information about the disease and treatment options


3. Which nursing intervention would be implemented when an 8.5 lb, 6 oz infant, delivered to a diabetic mother becomes jittery and lethargic?

a. Administer insulin

b. Administer oxygen

c. Feed the infant glucose water (10%)

d. Place infant in a warmer


4. A male client has just come in for a digital rectal examination. What important question should Nurse Abby ask from the patient?

a. “Have you noticed a change in the force of the urinary system?”

b. “Have you noticed a change in tolerance of certain foods in your diet?”

c. “Do you notice polyuria in the AM?”

d. “Do you notice any burning with urination or any odor to the urine?”


5. In assessing a prolonged late deceleration of the fetal heart rate of a client who is receiving oxytocin (Pitocin) IV to stimulate labor, the priority nursing intervention would be to:

a. Turn off the infusion

b. Turn the client to the left

c. Change the fluid to Ringer’s Lactate

d. Increase mainline IV rate


6. Nurse Gino is administering an oral medication to a 4 month old. Which appropriate nursing action should be used?

a. Place medication in 45cc of formula

b. Place medication in an empty nipple

c. Place medication in a full bottle of formula

d. Place in supine position. Administer medication using a plastic syringe


7. When caring for a 2 month old after surgery, which of the following should be the priority?

a. Minimize stimuli for the infant

b. Restrain all extremities

c. Encourage stroking of the infant

d. Demonstrate to the mother how she can assist with her infant’s care.


8. Jillian, a student nurse is assisting the staff nurse in performing a physical examination on a newborn, which assessment, according to what she has learned should be reported to the physician?

a. Head circumference of 40 cm

b. Chest circumference of 32 cm

c. Acrocyanosis and edema of the scalp

d. Heart rate of 160 and respirations of 40


9. Nurse Gina is about to give an injection to a preschooler. Which action by the mother of a preschooler would indicate a disturbed family interaction?

a. Tells her child that if he does not sit down and shut up she will leave him there.

b. Explains that the injection will burn like a bee sting.

c. Tells her child that the injection can be given while he’s in her lap

d. Reassures child that it is acceptable to cry.


10. Nurse Via knows that assessment and history taking is important in determining the condition of the client. During the history, which information from a 21 year old client would indicate a risk for development of testicular cancer?

a. Genital Herpes

b. Hydrocele

c. Measles

d. Undescended testicle


11. Nurse Albie notes a pulsating mass in the client’s periumbilical area upon caring for the patient. Which of the following assessments is appropriate for him to perform?

a. Measure the length of the mass

b. Auscultate the mass

c. Percuss the mass

d. Palpate the mass


12.When observing 4 year-old children playing in the hospital playroom, what activity would the Nurse Loki expect to see the children participating in?

a. Competitive board games with older children

b. Playing with their own toys along side with other children

c. Playing alone with hand held computer games

d. Playing cooperatively with other preschoolers


13. Nurse Lea is conducting health teaching and is teaching the parents of a 3 month-old infant about nutrition. What is the main source of fluids for an infant until about 12 months of age?

a. Formula or breastmilk

b. Dilute nonfat dry milk

c. Warmed fruit juice

d. Fluoridated tap water


14. Which of the following responses would be best given by the nurse when a client states “I do not want to take that medicine today”?

a. “That’s OK, its alright to skip your medication now and then.”

b. “I will have to call your doctor and report this.”

c. “Is there a reason why you don’t want to take your medicine?”

d. “Do you understand the consequences of refusing your prescribed treatment?”


15. In the assessment of a 4 month-old infant, which motor skill would the nurse anticipate finding?

a. Hold a rattle

b. Bang two blocks

c. Drink from a cup

d. Wave “bye-bye”


Answers and Rationale

1. Answer D.

Cranial nerves 9 and 10 are the glossopharyngeal and vagus nerves. The gag reflex would be evaluated.


2. Answer D.

Providing information for the client is the best technique for a new diagnosis.


3. Answer C.

After birth, the infant of a diabetic mother is often hypoglycemic.


4. Answer A.

This change would be most indicative of a potential complication with (BPH) benign prostate hypertrophy.


5. Answer A.

Stopping the infusion will decrease contractions and possibly remove uterine pressure on the fetus, which is a possible cause of the deceleration.


6. Answer B.

This is a convenient method for administering medications to an infant. Option D is partially correct however, the infant is never placed in a reclining position during a procedure due to a potential aspiration.


7. Answer C.

Tactile stimulation is imperative for an infant’s normal emotional development. After the trauma of surgery, sensory deprivation can cause failure to thrive.


8. Answer A.

Average circumference of the head for a neonate ranges between 32 to 36 cm. An increase in size may indicate hydrocephaly or increased intracranial pressure.


9. Answer A.

Threatening a child with abandonment will destroy the child’s trust in his family.


10. Answer D.

Undescended testicles make the client high risk for testicular cancer. Mumps, inguinal hernia in childhood, orchitis, and testicular cancer in the contralateral testis are other predisposing factors.


11. Answer B.

Auscultate the mass. Auscultation of the abdomen and finding a bruit will confirm the presence of an abdominal aneurysm and will form the basis of information given to the provider. The mass should not be palpated because of the risk of rupture.


12. Answer D.

Playing cooperatively with other preschoolers. Cooperative play is typical of the late preschool period.


13. Answer A.

Formula or breast milk are the perfect food and source of nutrients and liquids up to 1 year of age.


14. Answer C.

When a new problem is identified, it is important for the nurse to collect accurate assessment data. This is crucial to ensure that client needs are adequately identified in order to select the best nursing care approaches. The nurse should try to discover the reason for the refusal which may be that the client has developed untoward side effects.


15. Answer A.

The age at which a baby will develop the skill of grasping a toy with help is 4 to 6 months.


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