NCLEX-RN
NCLEX RN Prioritization Questions
1. A client was recently diagnosed with diverticulosis. What types of foods should the nurse recommend for this client?
- A. Whole grain cereal
- B. Eggs
- C. Cottage cheese
- D. Fish
Correct answer: A
Rationale: Diverticulosis is a condition characterized by small protrusions in the intestinal tract. To manage diverticulosis, a high-fiber diet is recommended. Foods rich in fiber help prevent constipation and reduce the risk of inflammation in the intestines. Whole grain cereals are an excellent source of fiber and can aid in maintaining bowel regularity. Eggs, cottage cheese, and fish are not high-fiber foods and may not provide the necessary dietary support for a client with diverticulosis. While protein-rich foods like eggs and fish are beneficial for overall health, they are not the primary recommendation for managing diverticulosis.
2. Which of the following signs is NOT indicative of increased intracranial pressure?
- A. Decreased level of consciousness
- B. Projectile vomiting
- C. Sluggish pupil dilation
- D. Increased heart rate
Correct answer: D
Rationale: Increased intracranial pressure can lead to serious complications if not promptly addressed. Common signs of increased intracranial pressure include decreased level of consciousness, sluggish pupil dilation, abnormal respirations, and projectile vomiting. However, an increased heart rate is not a typical sign associated with increased intracranial pressure. It is important for healthcare providers to recognize these signs early to prevent severe consequences such as brain herniation.
3. While taking the health history of a 70-year-old patient being treated for a Duodenal Ulcer, the nurse learns that the patient is complaining of epigastric pain. What assessment finding would the nurse expect to note?
- A. Melena
- B. Nausea
- C. Hernia
- D. Hyperthermia
Correct answer: A
Rationale: Melena is the passage of black, tarry stools due to the presence of blood in the gastrointestinal tract, usually originating from the upper digestive system. In the context of a Duodenal Ulcer, melena can occur as a result of bleeding in the duodenum or the upper part of the small intestine. This finding is significant as it indicates potential gastrointestinal bleeding, which is a common complication of duodenal ulcers. Nausea (Choice B) is a nonspecific symptom that may be present with various gastrointestinal conditions but is not specific to duodenal ulcers. Hernia (Choice C) involves the protrusion of an organ through the wall of the cavity that normally contains it and is not directly related to the symptoms of a duodenal ulcer. Hyperthermia (Choice D), which refers to an elevated body temperature, is not typically associated with duodenal ulcers unless there are severe complications present.
4. An 18-month-old child is being discharged after surgical repair of hypospadias. Which postoperative nursing care measure should the nurse stress to the parents as they prepare to take their child home?
- A. Leave the diapers on to protect the surgical site.
- B. Avoid tub baths until the stent has been removed.
- C. Delay toilet training until the child has fully recovered.
- D. Encourage adequate fluid intake to maintain hydration.
Correct answer: B
Rationale: After surgical repair of hypospadias, the nurse should stress to the parents to avoid giving the child a tub bath until the stent has been removed. This precaution helps prevent infection and ensures proper healing of the surgical site. Leaving diapers on is important to protect the surgical site from contamination. Delaying toilet training is recommended to reduce stress on the child during the recovery period. Encouraging adequate fluid intake is crucial to maintain hydration and support the healing process.
5. A 3-year-old child was brought to the pediatric clinic after the sudden onset of findings that include irritability, thick muffled voice, croaking on inspiration, being hot to the touch, sitting leaning forward, tongue protruding, drooling, and suprasternal retractions. What should the nurse do first?
- A. Prepare the child for an X-ray of the upper airways
- B. Examine the child's throat
- C. Collect a sputum specimen
- D. Notify the healthcare provider of the child's status
Correct answer: D
Rationale: The correct initial action is to notify the healthcare provider of the child's status. The presenting symptoms described, such as irritability, thick muffled voice, croaking on inspiration, being hot to the touch, sitting leaning forward, tongue protruding, drooling, and suprasternal retractions, are indicative of epiglottitis, a potentially life-threatening condition. Immediate medical attention is crucial in such cases. While preparing for an X-ray or examining the throat may be necessary, the priority is to ensure prompt evaluation and intervention by the healthcare provider. Collecting a sputum specimen is not relevant in this situation and would cause unnecessary delay. Therefore, the nurse should prioritize communication with the healthcare provider to expedite appropriate management and treatment.
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