NCLEX-RN
NCLEX RN Prioritization Questions
1. An older patient is receiving standard multidrug therapy for tuberculosis (TB). The nurse should notify the health care provider if the patient exhibits which finding?
- A. Yellow-tinged skin
- B. Orange-colored sputum
- C. Thickening of the fingernails
- D. Difficulty hearing high-pitched voices
Correct answer: A
Rationale: The correct answer is 'Yellow-tinged skin.' Yellow-tinged skin is indicative of noninfectious hepatitis, a toxic effect of isoniazid (INH), rifampin, and pyrazinamide. If a patient on TB therapy develops hepatotoxicity, alternative medications will be necessary. Thickening of fingernails and difficulty hearing high-pitched voices are not typical side effects of the medications used in standard TB therapy. Presbycusis, age-related hearing loss, is common in older adults and not a cause for immediate concern. Orange-colored sputum is an expected side effect of rifampin and does not warrant immediate notification to the healthcare provider.
2. 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.
3. The nurse provides preoperative instruction for a patient scheduled for a left pneumonectomy for lung cancer. Which information should the nurse include about the patient's postoperative care?
- A. Positioning on the right side
- B. Bed rest for the first 24 hours
- C. Frequent use of an incentive spirometer
- D. Chest tube placement with continuous drainage
Correct answer: C
Rationale: After a pneumonectomy, frequent deep breathing and coughing are essential to prevent atelectasis and promote gas exchange. Patients are typically positioned on the surgical side to aid in gas exchange. Early mobilization is crucial to reduce the risk of postoperative complications such as pneumonia and deep vein thrombosis. While chest tubes may or may not be placed in the surgical space, if used, they are clamped and only adjusted by the surgeon to manage serosanguineous fluid accumulation. Overfilling of the chest cavity can compromise remaining lung function and cardiovascular status. Chest x-rays are useful for monitoring fluid volume and space postoperatively. Therefore, the correct postoperative care instruction for the patient undergoing a left pneumonectomy is the frequent use of an incentive spirometer. Choices A, B, and D are incorrect as positioning on the right side, bed rest for the first 24 hours, and continuous chest tube drainage are not standard postoperative care practices for patients undergoing pneumonectomy.
4. A 49-year-old patient with multiple sclerosis (MS) is to begin treatment with glatiramer acetate (Copaxone). Which information will the nurse include in patient teaching?
- A. Recommendation to drink at least 4 L of fluid daily
- B. Need to avoid driving or operating heavy machinery
- C. How to draw up and administer injections of the medication
- D. Use of contraceptive methods other than oral contraceptives
Correct answer: C
Rationale: When initiating treatment with glatiramer acetate (Copaxone), patient education should focus on teaching the patient how to draw up and administer injections of the medication. Copaxone is administered via self-injection, hence understanding the correct technique is crucial for successful treatment. Recommendations regarding fluid intake or the need to avoid driving heavy machinery are not directly related to glatiramer acetate therapy. Additionally, while discussing contraceptive methods may be important, the use of oral contraceptives does not specifically contraindicate the use of glatiramer acetate.
5. A patient who was admitted the previous day with pneumonia complains of a sharp pain of 7 (based on a 0 to 10 scale) whenever taking a deep breath. Which action will the nurse take next?
- A. Auscultate breath sounds.
- B. Administer PRN morphine.
- C. Have the patient cough forcefully.
- D. Notify the patient's healthcare provider.
Correct answer: A
Rationale: The patient's complaint of sharp pain when taking a deep breath is concerning for pleurisy or pleural effusion. The nurse should auscultate breath sounds to assess for a pleural friction rub or decreased breath sounds, which could indicate these conditions. It is crucial to gather assessment data before initiating any pain medications. Asking the patient to cough forcefully may exacerbate the pain and should be avoided until further assessment. Contacting the healthcare provider should be based on the assessment findings; therefore, it is premature to notify the provider without conducting a thorough assessment first.
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