NCLEX-RN
NCLEX RN Prioritization Questions
1. A patient with right lower-lobe pneumonia has been treated with IV antibiotics for 3 days. Which assessment data obtained by the nurse indicates that the treatment has been effective?
- A. Bronchial breath sounds are heard at the right base.
- B. The patient coughs up small amounts of green mucus.
- C. The patients white blood cell (WBC) count is 9000/L
- D. Increased tactile fremitus is palpable over the right chest
Correct answer: C
Rationale: The normal WBC count indicates that the antibiotics have been effective. All the other data suggest that a change in treatment is needed.
2. While caring for the client during the first hour after delivery, the nurse determines that the uterus is boggy and there is vaginal bleeding. What should be the nurse's first action?
- A. Check vital signs.
- B. Massage the fundus.
- C. Offer a bedpan.
- D. Check for perineal lacerations.
Correct answer: B
Rationale: The nurse's first action should be to massage the fundus until it is firm as uterine atony is the primary cause of bleeding in the first hour after delivery. Massaging the fundus helps to stimulate uterine contractions, which can help control the bleeding. Checking vital signs would be important but addressing the primary cause of bleeding takes precedence. Offering a bedpan is not a priority in this situation as the focus should be on managing the postpartum bleeding. Checking for perineal lacerations is also important but not the initial action needed to address the boggy uterus and vaginal bleeding.
3. The nurse is working in a support group for clients with HIV. Which point is most important for the nurse to stress?
- A. They must inform household members of their condition.
- B. They must take their medications exactly as prescribed.
- C. They must abstain from substance use.
- D. They must avoid large crowds.
Correct answer: B
Rationale: The correct answer is that clients with HIV must take their medications exactly as prescribed. Antiretrovirals need to be taken as directed to prevent the development of drug-resistant strains and maintain treatment effectiveness. Missing doses can compromise the effectiveness of future treatments. Choice A, informing household members, is important for social support but not the most critical aspect of managing the condition. Choice C, abstaining from substance use, is important but not as crucial as medication adherence. Choice D, avoiding large crowds, is not directly related to HIV management as long as the individual's immune system is not significantly compromised.
4. A patient diagnosed with alopecia would be described as having:
- A. body lice
- B. lack of ear lobes
- C. Indigestion
- D. hair loss
Correct answer: D
Rationale: The correct answer is 'hair loss.' Alopecia is a medical term that specifically refers to the condition of hair loss, usually in patches or all over the body. Choice A, 'body lice,' refers to a parasitic infestation and is not related to alopecia. Choice B, 'lack of ear lobes,' is completely unrelated to the term alopecia, which is solely about hair loss. Choice C, 'Indigestion,' has no connection to alopecia as it pertains to digestive issues, not hair loss. Therefore, the correct description for a patient diagnosed with alopecia is 'hair loss.'
5. A patient with a cast on the right leg is being cared for by a nurse. Which of the following assessment findings would be most concerning for the nurse?
- A. The capillary refill time is 2 seconds
- B. The patient complains of itching and discomfort
- C. The cast has a foul-smelling odor
- D. The patient is on antibiotics
Correct answer: C
Rationale: A foul-smelling odor emanating from the cast is a concerning finding as it indicates the possibility of infection or the presence of a pressure ulcer. These conditions can lead to serious complications if not promptly addressed. It is crucial for the nurse to investigate further and take appropriate actions to prevent potential harm to the patient. The other options do not directly indicate a risk of infection or complications associated with the cast. Itching and discomfort are common complaints due to wearing a cast, and the patient being on antibiotics may be part of their treatment plan for an unrelated condition. Capillary refill time of 2 seconds is within the normal range and would not be a cause for immediate concern in this scenario.
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