QUESTIONS AND CORRECT

NCLEX Health Promotion & Maintenance COMPLETE REVISION

QUESTIONS AND CORRECT

DETAILED ANSWERS (VERIFIED

ANSWERS) ALREADY GRADED A+

The client has been working on weight loss for 8 months and has been successful in losing 35 lbs (15.9 kg). The client is now entering the maintenance phase of the health promotion plan. Which strategies are important for the nurse to emphasize as the client enters this phase?Select all that apply.

• On-going support from weight-loss program personnel.
• Periodic weigh-ins with the nurse.
• Discontinue programmatic exercise plan.
• Relapse prevention plan.
• Continued peer support. - Answer: 1. On-going support from weight-loss program personnel.
• Periodic weigh-ins with the nurse.
• Relapse prevention plan.
• Continued peer support.

(1., 2., 4. & 5. Correct: The person must have ongoing support to prevent a relapse. The weigh-ins increase accountability for prolonged behavioral change. Anytime that a new behavior is instituted, 1 / 4

there is a chance that the person will return to old habits. Having a plan in place may help the person to stay on track. Ongoing peer support can be very helpful as the client continues in the maintenance phase.

• Incorrect: Programmatic exercise, although reduced in frequency perhaps, should still be available. If

this is taken away or reduced too much, the client may return to old habits.) A nurse is caring for a 65 year-old client diagnosed with dehydration. The client has been receiving intravenous normal saline at 150 mL/hour for the past 4 hours. Which finding would the nurse need to notify the primary healthcare provider?

• Blood pressure 136/84
• Report of nausea
• Anxiety

4. Urinary output at 50 mL/hour - Answer: 3. Anxiety

(3. Correct: Anxiety, restlessness, or a sense of apprehension is often the first sign/symptoms of acute pulmonary edema.

• Incorrect: Blood pressure is normal. The number one concern right now is the anxiety: an early sign of

pulmonary edema.

• Incorrect: Although we would want to help the client having nausea, the anxiety is of upmost

importance, as it might indicate acute pulmonary edema.

• Incorrect: The client is dehydrated. A urinary output of 50 mL/hr, although low, is not at a critical

level. Signs of pulmonary edema will take priority.) 2 / 4

A nurse assesses the 5 minute Apgar on a term, newborn infant. Based on the Apgar score, what should be the nurse's priority intervention?

Activity (muscle tone): 1 (arms and legs flexed)

Pulse: 2 (> 100 bpm)

Grimace (reflex irritability): 1 (graimaces)

Appearance (skin color): 1 (Normal except extremities)

Respirations: 1 (slow, irregular)

• Continue Apgar scoring every five minutes until 20 minutes of life.
• Transfer newborn to the neonatal intensive care unit ASAP.
• Administer "blow-by" oxygen while suctioning.
• Perform cardiopulmonary resuscitation. - Answer: 3. Administer "blow-by" oxygen while suctioning.

(3. Correct: An Apgar score of 4, 5, or 6 requires immediate intervention, usually in the form of oxygen and respiratory assistance or in the form of suctioning if breathing has been obstructed by mucus. A source of oxygen called "blow-by" may be placed near but not directly over the nose and mouth of the newborn during suctioning.

• Incorrect: If the total score is below 7, or any area is scored 0 at 5 minutes, resuscitation efforts

should begin immediately and scoring should continue every 5 minutes until 20 minutes of life.Resuscitation is priority.

2. Incorrect: The priority is to begin resuscitation efforts.

• Incorrect: CPR is not needed at this point as the newborns heart rate is greater than 100 bpm.) 3 / 4

A client is admitted to the hospital with a platelet count of 132,000 mm³ and a white cell count of 8,495 cells/mcL. What interventions should the nurse implement?Select all that apply.

• Monitor stools for occult blood.
• Place on fall prevention.
• Place client in protective isolation.
• Restrict venipunctures.

5. Limit visitors. - Answer: 1. Monitor stools for occult blood.

• Place on fall prevention.
• Restrict venipunctures.

(1., 2., & 4. Correct: A normal platelet count ranges from 150,000-400,000 mm³. This is a low platelet count, so interventions should focus on bleeding precautions. The white cell count (WBC) is normal (5,000-10,000 cells/mcL). Bleeding precautions would include monitoring for bleeding, such as monitoring stools for occult blood. The client is at risk for injury, so fall prevention is needed. Since the client will bleed more easily, restrict venipunctures.

• Incorrect: The client has a normal white blood cell count, so protective isolation is not required.
• Incorrect: The client has a normal white blood cell count, so visitors do not have to be restricted.)

When caring for young adult clients, which developmental tasks would the nurse expect to see?Select all that apply.

• / 4