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

These answers are one of the NCLEX prep samples for Health Promotion and Maintenance. Click here to view the questions. If you want to answer all of our NCLEX questions interactively then be one of our member today. Click here to join. It’s Free.

1. D.  Clients should understand it is important to increase their fluid intake to at least 2000 ml each day. The increased fluid will assist in urate excretion and minimize urate precipitation in the urinary tract. Certain meats, such as organ meats and shellfish, are high in purine and should be restricted.

2. C. It is easier for infectious agents to travel from the nasopharyngeal area to the middle ear in younger than in older children because the eustachian tube is straighter when they are younger.

3. B. The test is done primarily to determine fetal trisomy 21 (Down’s syndrome) in pregnant women over 35 years of age. If the fetus is defective and the woman or couple do not wish to have an elective abortion, the procedure would probably not be performed due to its potential risk (though small) to the woman. Answer (C) is not correct as Ashkenazic Jews have a high incidence of Tay-Sachs disease. Although more difficult, amniocentesis may be performed on women carrying twins.

4. A. Liquids are not started until bowel sounds have returned; if there is no motility in the bowel, blockage could result. Clear liquid diets are started as soon as bowel sounds return. Diet protocol following major surgery begins with clear liquid to full liquid to soft to regular diet as tolerated.

5. A. Weights must hang freely off floor and bed to ensure countertraction. Ropes should be securely knotted, but they must move freely through pulleys. The client should not be pulled down in bed, because this position will negate the traction.

6. C. Whistling while exhaling or pursed-lip breathing prevents the bronchi from collapsing, thereby permitting more effective exhalation of trapped carbon dioxide. The other exercises do not foster exhalation of carbon dioxide.

7. A. Specific gravity results indicate the hydration status of the child. Children are NPO prior to the test so it is important that adequate hydration be accomplished following the procedure. Specific gravity does indicate the ability of the kidneys to concentrate or dilute urine, but in this case, the nurse would be looking for hydration status.

8. B. The client’s diet should be low residue and high calorie. Foods high in carbohydrates are usually low residue; chicken is acceptable without skin. Any salad, fresh vegetables, or grains would be considered high residue.

9. A. It is important that the brace remain on at all times except for bathing. It will also be important to teach her to use good skin care in the area where the brace touches her skin.

10. D. Prednisone, a corticosteroid, is the usual drug of choice. The other medication classifications are not used in the routine care of transplant clients.

11. D. Fruits and vegetables contain vitamin C and B. Vitamin B12 comes from animal products. Clients with pernicious anemia have a B12 deficiency. Clients either need frequent B12 injections or they must drastically increase the foods (such as meat, milk and cheese) that provide B12 in sufficient quantity.

12. B. The sides of fingertips have fewer nerve endings than do the balls of the finger, so less discomfort will result from selecting the sides as puncture sites. Both hands, including the thumbs, can be used as puncture sites.

13. D. The seventh cranial nerve supplies both motor and sensory function. The eyelid closure is a result of the motor function.

14. A. Constipation is a very common anti-cholinergic side effect of tricyclic antidepressant.  These side effects can be effectively treated with proper diet, fluids and exercise.  Choice 2 Routine blood levels need to be drawn on patient’s taking Lithium, to maintain therapeutic blood levels; Choice 3 – Patients on Phenothiazines must stay out of the sun to prevent photosensitivity reaction; Choice 4 – Cheese and wine need to be avoided for patients on MAO inhibitors, to prevent a hypertensive crisis.

15. A. 120-130 beats would be the average or normal range of heart rate for the child under one year of age.

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