NCLEX-RN
NCLEX RN Prioritization Questions
1. 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.
2. A patient is admitted to the emergency department with an open stab wound to the left chest. What is the first action that the nurse should take?
- A. Position the patient so that the left chest is dependent
- B. Tape a nonporous dressing on three sides over the chest wound
- C. Cover the sucking chest wound firmly with an occlusive dressing
- D. Keep the head of the patient's bed at no more than 30 degrees elevation
Correct answer: B
Rationale: The correct initial action for a patient with an open stab wound to the chest is to tape a nonporous dressing on three sides over the chest wound. This dressing technique allows air to escape during expiration but prevents air from entering the pleural space during inspiration, helping to prevent tension pneumothorax. Placing the patient so that the left chest is dependent or covering the wound with an occlusive dressing can trap air in the pleural space, leading to tension pneumothorax. Keeping the head of the bed elevated at 30 to 45 degrees helps facilitate breathing and is not the first action to take when managing an open chest wound.
3. Following assessment of a patient with pneumonia, the nurse identifies a nursing diagnosis of ineffective airway clearance. Which assessment data best supports this diagnosis?
- A. Weak, nonproductive cough effort
- B. Large amounts of greenish sputum
- C. Respiratory rate of 28 breaths/minute
- D. Resting pulse oximetry (SpO2) of 85%
Correct answer: A
Rationale: The correct answer is 'Weak, nonproductive cough effort.' A weak, nonproductive cough indicates that the patient is unable to clear the airway effectively, supporting the nursing diagnosis of ineffective airway clearance. In pneumonia, secretions can obstruct the airway, leading to ineffective clearance. Choices B, C, and D do not directly reflect ineffective airway clearance. Large amounts of greenish sputum (Choice B) may suggest infection or inflammation but do not specifically indicate ineffective airway clearance. The respiratory rate of 28 breaths/minute (Choice C) and a resting pulse oximetry (SpO2) of 85% (Choice D) are more indicative of impaired gas exchange or respiratory distress rather than ineffective airway clearance.
4. A patient with acute shortness of breath is admitted to the hospital. Which action should the nurse take during the initial assessment of the patient?
- A. Ask the patient to lie down to complete a full physical assessment.
- B. Briefly ask specific questions about this episode of respiratory distress.
- C. Complete the admission database to check for allergies before treatment.
- D. Delay the physical assessment to first complete pulmonary function tests.
Correct answer: B
Rationale: When a patient presents with acute shortness of breath, the initial assessment should focus on gathering specific information relevant to the current episode of respiratory distress. A comprehensive health history or full physical examination can be deferred until the acute distress has been addressed. Asking specific questions helps determine the cause of the distress and guides appropriate treatment. While checking for allergies is important, completing the entire admission database is not a priority during the initial assessment. Likewise, delaying the physical assessment for pulmonary function tests is not recommended as the immediate focus should be on addressing the acute respiratory distress before ordering further diagnostic tests or interventions.
5. When assessing the respiratory system of an older patient, which finding indicates that the nurse should take immediate action?
- A. Weak cough effort
- B. Barrel-shaped chest
- C. Dry mucous membranes
- D. Bilateral crackles at lung bases
Correct answer: D
Rationale: Bilateral crackles at lung bases indicate a potential acute issue like heart failure. Immediate action is necessary in this situation. The nurse should conduct further assessments such as oxygen saturation and inform the healthcare provider promptly. A barrel-shaped chest and hyperresonance to percussion are typical signs of aging and do not require immediate action. A weak cough effort is common in older patients due to age-related changes, and dry mucous membranes are also expected in older individuals. While these findings may warrant further evaluation, they do not demand immediate action like bilateral crackles at lung bases.
Similar Questions
Access More Features
NCLEX RN Basic
$69.99/ 30 days
- 5,000 Questions with answers
- Comprehensive NCLEX coverage
- 30 days access @ $69.99
NCLEX RN Premium
$149.99/ 90 days
- 5,000 Questions with answers
- Comprehensive NCLEX coverage
- 30 days access @ $149.99