NCLEX Updated NCLEX-PN Exam Questions and Answers by marlie

The nurse should immediately obtain a Doppler device and recheck the pulses. The dorsalis pedis and posterior tibial can be difficult to assess and might need to be verified with a Doppler. Because the client just had a surgery in which a complication is arterial insufficiency, the client must be monitored carefully. If the pulses are not found, the nurse should recognize that this is an emergent situation, and the physician must be notified immediately. If the nurse waits 30 minutes before determining if the pulses can be felt, this could compromise the viability of the client’s foot due to ischemia. Documenting the findings is important but must be performed after the nurse locates the dorsalis pedis and posterior tibial pulses or any necessary interventions are made.Health Promotion and Maintenance

The client is describing signs and symptoms of tuberculosis. The client is potentially infectious to others and should be secluded. A respirator mask should be worn by caregivers, but it is not necessary for the nurse to don a gown and gloves. If the client is moved to other areas such as radiology, a mask should be worn by the client and a respirator mask should be worn by those working in close contact with the client.Safety and Infection Control

Choice 3 is indicative of a tension pneumothorax, which is considered a medical emergency. The respiratory system is severely compromised and venous return to the heart is affected. The mediastinal shift is to the unaffected side. Choice 1 contains symptoms of pleurisy, and Choice 2 lists symptoms of bronchitis. Neither are emergencies. The client in Choice 4 should expect difficulty breathing after exercise when asthma is an existing condition and might need immediate attention if his rescue inhaler is ineffective.Physiological Adaptation

Primary prevention involves activities that are utilized to promote wellness or prevent illness or injury. There are many dangers in the home for small children. Providing education regarding the need for safety measures to prevent injury in the home is considered primary prevention. Secondary prevention involves early detection of a disease or illness and quick intervention to aid the client in maintenance of the disease or injury. Tertiary prevention involves the reduction of a disability and the promotion of the highest level of functioning for a client in relation to his or her disease or injury. Health promotion is any activity that increases a client’s health and wellness.Health Promotion and Maintenance