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 laboratory test result should the nurse monitor to evaluate the effects of therapy for a 62-year-old female patient with acute pancreatitis?
- A. Calcium
- B. Bilirubin
- C. Amylase
- D. Potassium
Correct answer: C
Rationale: The correct answer is C: Amylase. In acute pancreatitis, amylase levels are typically elevated. Monitoring amylase levels helps assess the effectiveness of therapy in managing the condition. Elevated amylase is a key indicator of pancreatic inflammation. Calcium (Choice A) levels may be affected in pancreatitis, but they are not the primary indicator for evaluating therapy effectiveness. Bilirubin (Choice B) and Potassium (Choice D) levels may also be altered in pancreatitis, but they are not specific markers for monitoring therapy response in acute pancreatitis.
3. 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.
4. What is the most common complication of chest wall injury?
- A. Hemothorax
- B. Atelectasis
- C. Pneumonia
- D. Pneumothorax
Correct answer: C
Rationale: Pneumonia is the most common complication of chest wall injury. Chest wall trauma can lead to impaired lung function, making patients more susceptible to pneumonia due to reduced ability to clear secretions and impaired breathing. While hemothorax and pneumothorax are potential complications of chest wall injury, pneumonia is more commonly encountered. Atelectasis, although a common pulmonary complication, is not typically the most common complication seen in chest wall injuries.
5. A client in end-stage renal disease is receiving peritoneal dialysis at home. The nurse must educate the client about potential complications associated with this procedure. All of the following are complications associated with peritoneal dialysis EXCEPT:
- A. Hypotriglyceridemia
- B. Abdominal hernia
- C. Anorexia
- D. Peritonitis
Correct answer: A
Rationale: Peritoneal dialysis poses risks of various complications, including abdominal hernia, anorexia, peritonitis, and other issues. However, hypotriglyceridemia is not a common complication associated with peritoneal dialysis. The nurse should focus on educating the client about the risks of developing peritonitis, abdominal hernias, anorexia, low back pain, and abdominal bleeding. Monitoring triglyceride levels is essential for managing lipid disorders but is not directly linked to peritoneal dialysis complications.
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