NCLEX-RN
NCLEX RN Prioritization Questions
1. One hour after a thoracotomy, a patient complains of incisional pain at a level 7 (based on a 0 to 10 scale) and has decreased left-sided breath sounds. The pleural drainage system has 100 mL of bloody drainage and a large air leak. Which action is best for the nurse to take next?
- A. Milk the chest tube gently to remove any clots.
- B. Clamp the chest tube momentarily to check for the origin of the air leak.
- C. Assist the patient to deep breathe, cough, and use the incentive spirometer.
- D. Set up the patient-controlled analgesia (PCA) and administer the loading dose of morphine.
Correct answer: S
Rationale: In this scenario, the best action is to set up the patient-controlled analgesia (PCA) and administer the loading dose of morphine. The patient's pain level is high, which can hinder deep breathing and coughing. Addressing pain control is a priority to facilitate optimal respiratory function. Milking the chest tube to remove clots is unnecessary as the drainage amount is not alarming in the early postoperative period. Clamping the chest tube to locate the air leak is not recommended as it can lead to tension pneumothorax. Assisting the patient to deep breathe, cough, and use the incentive spirometer is important but should follow adequate pain management to ensure the patient can effectively participate in these activities.
2. Which factors will the nurse consider when calculating the CURB-65 score for a patient with pneumonia? (Select one that does not apply)
- A. Age
- B. Blood pressure
- C. Respiratory rate
- D. Oxygen saturation
Correct answer: D
Rationale: The correct answer is 'Oxygen saturation.' When calculating the CURB-65 score for a patient with pneumonia, the factors considered include mental status (confusion), BUN (elevated), blood pressure (decreased), respiratory rate (increased), and age (65 and older). Oxygen saturation is not used in the CURB-65 scoring system. While blood pressure, respiratory rate, and age are factors that are used in the calculation of the CURB-65 score, oxygen saturation is not part of the scoring criteria. Therefore, oxygen saturation is the factor that does not apply when calculating the CURB-65 score.
3. While caring for a patient with respiratory disease, the nurse observes that the patient's SpO2 drops from 93% to 88% while the patient is ambulating in the hallway. What is the priority action of the nurse?
- A. Notify the healthcare provider
- B. Document the response to exercise
- C. Administer the PRN supplemental O2
- D. Encourage the patient to pace activity
Correct answer: C
Rationale: The drop in SpO2 to 88% indicates that the patient is hypoxemic and needs supplemental oxygen when exercising. Administering PRN supplemental oxygen is the priority action to correct the hypoxemia and ensure adequate oxygenation during activity. Notifying the healthcare provider can be done after stabilizing the patient's oxygen levels. Documenting the response to exercise is important but secondary to addressing the immediate hypoxemia. Encouraging the patient to pace activity is not sufficient to address the acute drop in SpO2 and provide the necessary oxygen support.
4. A pregnant woman who is 36 weeks' pregnant and has hepatitis B is being informed by a nurse. Which of the following statements from the client indicates understanding of this condition?
- A. Now I know my baby will need a cesarean section.
- B. My baby will need two shots soon after birth.
- C. I will not be able to breastfeed.
- D. My baby's father does not need testing; I know I am the one with hepatitis.
Correct answer: B
Rationale: The correct answer is 'My baby will need two shots soon after birth.' A baby born to a mother with hepatitis B should receive two injections soon after birth to reduce the risk of contracting the disease. Within the first 12 hours post-birth, the baby should receive the first hepatitis B vaccine and hepatitis B immune globulin (HBIG) for additional protection. Option A is incorrect because the need for a cesarean section is not directly related to the mother's hepatitis B status. Option C is incorrect as breastfeeding can be safe if managed properly. Option D is incorrect as the baby's father should also be tested for hepatitis B to prevent transmission to the newborn.
5. While auscultating a patient's lungs, the nurse hears low-pitched, bubbling sounds during inhalation in the lower third of both lungs. How should the nurse document this finding?
- A. Inspiratory crackles at the bases
- B. Expiratory wheezes in both lungs
- C. Abnormal lung sounds in the apices of both lungs
- D. Pleural friction rub in the right and left lower lobes
Correct answer: A
Rationale: The correct answer is 'Inspiratory crackles at the bases.' Crackles are low-pitched, bubbling sounds typically heard during inspiration, which aligns with the nurse's finding. Expiratory wheezes are high-pitched sounds and are not consistent with the described auscultation findings. The lower third of both lungs refers to the bases, not the apices, so option C is incorrect. Pleural friction rubs are grating sounds heard during both inspiration and expiration, unlike the described finding of only hearing the sounds during inhalation in the lower third of both lungs.
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