NCLEX-RN
NCLEX RN Prioritization Questions
1. A patient experiences a chest wall contusion as a result of being struck in the chest with a baseball bat. The emergency department nurse would be most concerned if which finding is observed during the initial assessment?
- A. Paradoxic chest movement
- B. Complaint of chest wall pain
- C. Heart rate of 110 beats/minute
- D. Large bruised area on the chest
Correct answer: A
Rationale: Paradoxic chest movement is the most concerning finding as it indicates a potential flail chest, which can lead to severe compromise in gas exchange and rapid hypoxemia. This condition requires immediate attention to prevent respiratory distress. Complaint of chest wall pain, a slightly elevated heart rate, and a large bruised area on the chest are important assessment findings but may not immediately threaten gas exchange or respiratory function. Therefore, identifying paradoxic chest movement is critical for prompt intervention and management.
2. Which clinical manifestations are recognized in nephrotic syndrome?
- A. Hematuria, bacteriuria, weight gain
- B. Gross hematuria, albuminuria, fever
- C. Hypertension, weight loss, proteinuria
- D. Massive proteinuria, hypoalbuminemia, edema
Correct answer: D
Rationale: Nephrotic syndrome is characterized by massive proteinuria, hypoalbuminemia, and edema. In this syndrome, there is loss of proteins, particularly albumin, in the urine leading to hypoalbuminemia, fluid retention, and subsequent edema. This results in elevated lipid levels like hypercholesterolemia, but not hypertension. Therefore, choices A, B, and C are incorrect. Hematuria, bacteriuria, fever, and weight loss are not typically associated with nephrotic syndrome, distinguishing it from other kidney disorders.
3. Rhogam is most often used to treat____ mothers that have a ____ infant.
- A. RH positive, RH positive
- B. RH positive, RH negative
- C. RH negative, RH positive
- D. RH negative, RH negative
Correct answer: C
Rationale: Rhogam is administered to RH-negative mothers who have an RH-positive infant to prevent the development of anti-RH antibodies in the mother's system. Choice A (RH positive, RH positive) is incorrect because Rhogam is not used when both mother and infant are RH positive. Choice B (RH positive, RH negative) is incorrect because Rhogam is used when the mother is RH negative, not RH positive. Choice D (RH negative, RH negative) is incorrect as Rhogam is not typically needed if both mother and infant are RH negative.
4. Your patient has shown the following signs and symptoms: Feeling very thirsty, large amount of water intake, dryness of the mouth, and urinary frequency. What physical disorder does this patient most likely have?
- A. Diabetes
- B. Angina
- C. Hypertension
- D. Hypotension
Correct answer: A
Rationale: The patient is exhibiting classic signs of diabetes, such as polydipsia (feeling very thirsty), polyuria (large amount of water intake and urinary frequency), and xerostomia (dryness of the mouth). These symptoms are indicative of high blood glucose levels, which are characteristic of diabetes. Other common signs of diabetes include poor vision, unexplained weight loss, peripheral neuropathy (tingling in the feet and hands), and fatigue. Angina is chest pain due to reduced blood flow to the heart, not associated with the symptoms described in the patient. Hypertension is high blood pressure, which typically does not present with these specific symptoms related to diabetes. Hypotension is low blood pressure and is not consistent with the signs and symptoms presented by the patient, pointing more towards diabetes as the likely diagnosis.
5. A patient asks a nurse administering blood how long red blood cells live in the body. What is the correct response?
- A. The life span of RBC is 45 days
- B. The life span of RBC is 60 days
- C. The life span of RBC is 90 days
- D. The life span of RBC is 120 days
Correct answer: D
Rationale: The correct answer is that red blood cells have a lifespan of 120 days in the body. This allows for efficient oxygen transport throughout the circulatory system. Choices A, B, and C are incorrect because the lifespan of red blood cells is actually 120 days. Understanding the lifespan of red blood cells is crucial in assessing various conditions related to blood cell production and turnover.
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