NCLEX-RN
NCLEX RN Prioritization Questions
1. The nurse monitors a patient after chest tube placement for a hemopneumothorax. The nurse is most concerned if which assessment finding is observed?
- A. A large air leak in the water-seal chamber
- B. 400 mL of blood in the collection chamber
- C. Complaint of pain with each deep inspiration
- D. Subcutaneous emphysema at the insertion site
Correct answer: B
Rationale: The nurse should be most concerned if 400 mL of blood is observed in the collection chamber as it may indicate the patient is at risk of developing hypovolemic shock. A large air leak in the water-seal chamber is expected initially after chest tube placement for a pneumothorax. While pain with deep inspiration should be treated, it is not as urgent as the risk of continued hemorrhage. Subcutaneous emphysema is not uncommon in a patient with pneumothorax and is usually harmless. However, a large amount of blood in the collection chamber is a more critical finding that requires immediate attention to prevent potential complications.
2. A child is prescribed baclofen (Lioresal) via intrathecal pump to treat severe muscle spasms related to cerebral palsy. What teaching does the nurse provide the child and parents?
- A. Do not let this prescription run out.
- B. The medication may cause gingival hyperplasia.
- C. Periodic serum drug levels are needed.
- D. Watch for excessive facial hair growth.
Correct answer: A
Rationale: The correct teaching for the child and parents when a child is prescribed baclofen via an intrathecal pump is to not let the prescription run out. Abrupt discontinuation of intrathecal baclofen can lead to severe effects like high fever, altered mental status, and rebound spasticity and muscle rigidity. It is crucial for the parents to ensure there is always an adequate supply of this medication to prevent these adverse effects. Choices B and D are incorrect because gingival hyperplasia and hirsutism are side effects associated with phenytoin (Dilantin), not baclofen. Choice C is incorrect as serum drug levels are not typically monitored for intrathecal medications.
3. A client is found unresponsive in his room by a nurse. The client is not breathing and does not have a pulse. After calling for help, what is the next action the nurse should take?
- A. Administer 2 ventilations
- B. Perform a head-tilt, chin lift to open the airway
- C. Begin chest compressions
- D. Perform a jaw thrust to open the airway
Correct answer: C
Rationale: After finding an unresponsive client who is not breathing and has no pulse, the nurse's immediate action should be to call for help and start chest compressions. Chest compressions should be initiated at a rate of at least 100 per minute and a depth of at least 2 inches. Choice A, administering ventilations, is not the initial step as compressions take priority. Choice B, performing a head-tilt, chin lift, is also not the first step; chest compressions are crucial before airway management. Choice D, performing a jaw thrust, is typically used in cases of suspected cervical spine injury and is not the immediate action in this scenario.
4. The patient with idiopathic pulmonary arterial hypertension (IPAH) is receiving epoprostenol (Flolan). Which assessment information requires the most immediate action by the nurse?
- A. The oxygen saturation is 94%.
- B. The blood pressure is 98/56 mm Hg.
- C. The patient's central IV line is disconnected.
- D. The international normalized ratio (INR) is prolonged.
Correct answer: C
Rationale: The most immediate action required by the nurse is to address the disconnected central IV line delivering epoprostenol (Flolan). Epoprostenol has a short half-life of 6 minutes, necessitating immediate reconnection to prevent rapid clinical deterioration. While oxygen saturation, blood pressure, and INR are important parameters requiring monitoring and intervention, the priority lies in ensuring the continuous delivery of the critical medication to stabilize the patient's condition.
5. When auscultating the patient's lungs during a shift assessment on a patient admitted in the early phase of heart failure, which finding would the nurse most likely hear?
- A. Continuous rumbling, snoring, or rattling sounds mainly on expiration
- B. Continuous high-pitched musical sounds on inspiration and expiration
- C. Discontinuous, high-pitched sounds of short duration heard on inspiration
- D. A series of long-duration, discontinuous, low-pitched sounds during inspiration
Correct answer: C
Rationale: In the early phase of heart failure, fine crackles are likely to be heard upon auscultation of the lungs. Fine crackles are characterized as discontinuous, high-pitched sounds of short duration heard on inspiration. Rhonchi are continuous rumbling, snoring, or rattling sounds mainly on expiration, which are often associated with airway secretions. Coarse crackles are a series of long-duration, discontinuous, low-pitched sounds during inspiration, typically indicating fluid in the alveoli. Wheezes are continuous high-pitched musical sounds on inspiration and expiration, commonly heard in conditions like asthma or chronic obstructive pulmonary disease (COPD). Therefore, the correct choice is C, as it describes the expected lung sounds in a patient with early heart failure.
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