NCLEX NCLEX-RN
NCLEX RN Prioritization Questions
1. 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: Auscultate breath sounds.
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.
2. Which instruction is most important for the nurse to include when teaching a client with limited mobility strategies to prevent venous thrombosis?
- A. Perform cough and deep breathing exercises hourly.
- B. Turn from side to side in bed at least every 2 hours.
- C. Dorsiflex and plantarflex the feet 10 times each hour
- D. Drink approximately 4 ounces of water every hour
Correct answer: Dorsiflex and plantarflex the feet 10 times each hour
Rationale: To reduce the risk of venous thrombosis, the nurse should instruct the client to perform dorsiflexion and plantar flexion exercises regularly. These exercises help promote venous return and prevent venous thrombus formation. Options A, B, and D are beneficial in managing other complications of immobility, such as atelectasis and pressure ulcers, but they are less effective in preventing venous thrombosis compared to dorsiflexion and plantar flexion exercises.
3. A client is found unresponsive in his room by a nurse. The client is not breathing and does not have a pulse. After calling for help, what is the next action the nurse should take?
- A. Administer 2 ventilations
- B. Perform a head-tilt, chin lift to open the airway
- C. Begin chest compressions
- D. Perform a jaw thrust to open the airway
Correct answer: C: Begin chest compressions
Rationale: After finding an unresponsive client who is not breathing and has no pulse, the nurse's immediate action should be to call for help and start chest compressions. Chest compressions should be initiated at a rate of at least 100 per minute and a depth of at least 2 inches. Choice A, administering ventilations, is not the initial step as compressions take priority. Choice B, performing a head-tilt, chin lift, is also not the first step; chest compressions are crucial before airway management. Choice D, performing a jaw thrust, is typically used in cases of suspected cervical spine injury and is not the immediate action in this scenario.
4. What procedure examines a portion of the large intestine with an endoscope?
- A. Colposcopy
- B. Sigmoidoscopy
- C. Upper GI
- D. Cardiac catheterization
Correct answer: B: Sigmoidoscopy
Rationale: Sigmoidoscopy is the correct answer because it specifically examines the sigmoid colon located in the descending colon using an endoscope inserted through the rectum. This procedure captures video and images of the large intestine's lining, helping in the diagnosis of conditions like inflammatory bowel disease or colorectal cancer. Colposcopy, on the other hand, is a procedure for examining the cervix and vagina, not the large intestine. Upper GI involves capturing images of the esophagus and stomach, focusing on the upper gastrointestinal tract, not the large intestine. Cardiac catheterization is a procedure that involves threading a thin instrument through the femoral artery to the heart, used for cardiac interventions and not related to examining the large intestine.
5. The client is receiving discharge teaching seven (7) days post myocardial infarction and inquires why he must wait six (6) weeks before engaging in sexual intercourse. What is the best response by the nurse to this question?
- A. “You need to regain your strength before attempting such exertion.”
- B. “When you can climb 2 flights of stairs without problems, it is generally safe.”
- C. “Have a glass of wine to relax you, then you can try to have sex.”
- D. “If you can maintain an active walking program, you will have less risk.”
Correct answer: “When you can climb 2 flights of stairs without problems, it is generally safe.”
Rationale: Following a myocardial infarction, there is a risk of cardiac rupture at the site of the infarction for approximately six (6) weeks until scar tissue forms. The advice to wait until the client can climb two flights of stairs without issues is common among healthcare providers as it indicates an adequate level of physical exertion tolerance and suggests a lower risk of complications during sexual activity. Choice A is not specific to the recovery timeline related to sexual activity post-myocardial infarction. Choice C is inappropriate as alcohol consumption should not be recommended before sexual activity. Choice D, though promoting an active lifestyle, does not directly address the safety concerns related to sexual intercourse post-myocardial infarction.
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