1|Page
NCLEX-RN Health Promotion and Maintenance 1-5
Complete Exam (2025/2026) | 400+ Verified Q&A |
Foundational to Specialist Level||Latest Exam!!!
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.
1. On-going support from weight-loss program personnel.
2. Periodic weigh-ins with the nurse.
3. Discontinue programmatic exercise plan.
4. Relapse prevention plan.
5. Continued peer support. - Answer-1. On-going support
from weight-loss program personnel.
,2|Page
2. Periodic weigh-ins with the nurse.
4. Relapse prevention plan.
5. 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, 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.
3. 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
,3|Page
finding would the nurse need to notify the primary
healthcare provider?
1. Blood pressure 136/84
2. Report of nausea
3. 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.
1. Incorrect: Blood pressure is normal. The number one
concern right now is the anxiety: an early sign of
pulmonary edema.
2. Incorrect: Although we would want to help the client
having nausea, the anxiety is of upmost importance, as it
might indicate acute pulmonary edema.
, 4|Page
4. 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.)
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)
1. Continue Apgar scoring every five minutes until 20
minutes of life.
2. Transfer newborn to the neonatal intensive care unit
ASAP.
3. Administer "blow-by" oxygen while suctioning.
NCLEX-RN Health Promotion and Maintenance 1-5
Complete Exam (2025/2026) | 400+ Verified Q&A |
Foundational to Specialist Level||Latest Exam!!!
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.
1. On-going support from weight-loss program personnel.
2. Periodic weigh-ins with the nurse.
3. Discontinue programmatic exercise plan.
4. Relapse prevention plan.
5. Continued peer support. - Answer-1. On-going support
from weight-loss program personnel.
,2|Page
2. Periodic weigh-ins with the nurse.
4. Relapse prevention plan.
5. 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, 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.
3. 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
,3|Page
finding would the nurse need to notify the primary
healthcare provider?
1. Blood pressure 136/84
2. Report of nausea
3. 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.
1. Incorrect: Blood pressure is normal. The number one
concern right now is the anxiety: an early sign of
pulmonary edema.
2. Incorrect: Although we would want to help the client
having nausea, the anxiety is of upmost importance, as it
might indicate acute pulmonary edema.
, 4|Page
4. 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.)
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)
1. Continue Apgar scoring every five minutes until 20
minutes of life.
2. Transfer newborn to the neonatal intensive care unit
ASAP.
3. Administer "blow-by" oxygen while suctioning.
