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. The nurse is caring for a patient who has recently had a successful catheter ablation. Which assessment finding demonstrates a successful outcome of this procedure?
- A. The patient is free of electrolyte imbalances
- B. The patient's WBC count is within normal limits
- C. The patient's EKG reading is regular
- D. The patient's urine output is 45 mL/hour
Correct answer: C
Rationale: A successful outcome of a catheter ablation procedure for arrhythmias, particularly SVT, is indicated by a regular EKG reading. Catheter ablation involves the use of radiofrequency energy to destroy the conduction fiber in the heart responsible for the arrhythmia. This destruction helps in preventing further episodes of arrhythmia. While choices A, B, and D are important assessments in patient care, they are not specific indicators of the success of a catheter ablation procedure. Electrolyte imbalances, WBC count, and urine output can be affected by various factors and are not directly related to the effectiveness of a catheter ablation in treating arrhythmias.
3. A patient with newly diagnosed lung cancer tells the nurse, 'I don't think I'm going to live to see my next birthday.' Which response by the nurse is best?
- A. Would you like to talk to the hospital chaplain about your feelings?
- B. Can you tell me what it is that makes you think you will die so soon?
- C. Are you afraid that the treatment for your cancer will not be effective?
- D. Do you think that taking an antidepressant medication would be helpful?
Correct answer: B
Rationale: The nurse's initial response should be to collect more assessment data about the patient's statement. The answer beginning 'Can you tell me what it is' is the most open-ended question and will offer the best opportunity for obtaining more data. The answer beginning 'Are you afraid' implies that the patient thinks that the cancer will be immediately fatal, although the patient's statement may not be related to the cancer diagnosis. The remaining two answers offer interventions that may be helpful to the patient, but more assessment is needed to determine whether these interventions are appropriate.
4. The nurse analyzes the results of a patient's arterial blood gases (ABGs). Which finding would require immediate action?
- A. The bicarbonate level (HCO3) is 31 mEq/L
- B. The arterial oxygen saturation (SaO2) is 92%
- C. The partial pressure of CO2 in arterial blood (PaCO2) is 31 mm Hg
- D. The partial pressure of oxygen in arterial blood (PaO2) is 59 mm Hg
Correct answer: D
Rationale: While all the values are abnormal, the low PaO2 level of 59 mm Hg indicates that the patient is at a critical point on the oxyhemoglobin dissociation curve. At this level, a small decrease in PaO2 can lead to a significant drop in oxygen saturation and compromise tissue oxygenation. Therefore, immediate intervention is necessary to improve the patient's oxygenation status. Choice A (HCO3 of 31 mEq/L) may indicate metabolic alkalosis or compensation for respiratory acidosis; however, it does not require immediate action in this scenario. Choice B (SaO2 of 92%) is slightly low but not critically low to require immediate action. Choice C (PaCO2 of 31 mm Hg) is within the normal range and does not indicate immediate danger to the patient.
5. The nurse assesses a patient suspected of having meningitis. Which of the following is a common clinical manifestation of this condition?
- A. A high WBC count and decreased level of consciousness
- B. A high WBC count and manic activity
- C. A low WBC count and manic activity
- D. A low WBC count and decreased level of consciousness
Correct answer: A
Rationale: The correct answer is 'A high WBC count and decreased level of consciousness.' Meningitis is often caused by an infectious organism, leading to an increase in Intracranial Pressure (ICP), which can result in decreased level of consciousness. While meningitis can trigger an inflammatory response, it typically presents with an elevated white blood cell (WBC) count rather than a low WBC count. Manic activity is not a common clinical manifestation of meningitis; instead, patients may exhibit altered mental status, confusion, or lethargy.
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