NCLEX NCLEX-RN
NCLEX RN Prioritization Questions
1. An alcoholic and homeless patient is diagnosed with active tuberculosis (TB). Which intervention by the nurse will be most effective in ensuring adherence with the treatment regimen?
- A. Arrange for a friend to administer the medication on schedule.
- B. Give the patient written instructions about how to take the medications.
- C. Teach the patient about the high risk for infecting others unless treatment is followed.
- D. Arrange for a daily noon meal at a community center where the drug will be administered
Correct answer: Arrange for a daily noon meal at a community center where the drug will be administered
Rationale: Directly observed therapy is the most effective means for ensuring compliance with the treatment regimen for a homeless patient with active tuberculosis. By arranging a daily noon meal at a community center where the drug will be administered, the nurse ensures that the patient is available to receive the medication and can directly observe the patient taking it. This method helps address the challenges faced by homeless individuals, such as lack of a stable living situation. The other options, such as having a friend administer the medication, giving written instructions, or educating about infecting others, may not be as effective in ensuring adherence, especially in the case of a homeless individual with alcoholism.
2. While performing CPR, a healthcare provider encounters a client with a large amount of thick chest hair when preparing to use an automated external defibrillator (AED). What is the next appropriate action for the healthcare provider?
- A. Apply the pads to the chest and provide a shock
- B. Wipe the client's chest down with a towel before applying the pads
- C. Shave the client's chest to remove the hair
- D. Do not use the AED
Correct answer: Shave the client's chest to remove the hair
Rationale: When using an AED, it is crucial for the pads to have good contact with the skin to effectively deliver an electrical shock. While AED pads can adhere to a client's chest even with some hair, thick chest hair can hinder proper current conduction. In such cases, it is recommended to shave the area of the chest where the pads will be applied. Most AED kits include a razor for this purpose. The healthcare provider should act promptly to minimize delays in defibrillation. Option A is incorrect because it may lead to ineffective treatment due to poor pad adherence. Option B is not the best course of action as wiping the chest may not resolve the issue of poor pad contact. Option D is incorrect as not using the AED could jeopardize the client's chance of survival in a cardiac emergency.
3. The nurse practicing in a maternity setting recognizes that the postmature fetus is at risk due to:
- A. Excessive fetal weight
- B. Low blood sugar levels
- C. Depletion of subcutaneous fat
- D. Progressive placental insufficiency
Correct answer: Progressive placental insufficiency
Rationale: A postmature or postterm pregnancy occurs when a pregnancy exceeds the typical term of 38 to 42 weeks. In this situation, the fetus is at risk due to progressive placental insufficiency. This occurs because the placenta loses its ability to function effectively after 42 weeks. The accumulation of calcium deposits in the placenta reduces blood perfusion, oxygen supply, and nutrient delivery to the fetus, leading to potential growth problems. Choices A, B, and C are incorrect because excessive fetal weight, low blood sugar levels, and depletion of subcutaneous fat are not the primary risks associated with postmature fetuses. The main concern lies in the compromised placental function and its impact on fetal well-being.
4. To which of the following do the CDC Standard precautions recommendations apply?
- A. Patients with diagnosed infections only
- B. Blood or body fluids with visible blood only
- C. All body fluids including sweat
- D. All patients receiving care in hospitals
Correct answer: All patients receiving care in hospitals
Rationale: The correct answer is 'All patients receiving care in hospitals.' Standard precautions apply to all patients in healthcare settings, regardless of their infection status. These recommendations include all body fluids except sweat, non-intact skin, and mucous membranes. Choice A is incorrect as standard precautions are not limited to patients with diagnosed infections. Choice B is incorrect as standard precautions extend beyond blood or body fluids with visible blood. Choice C is incorrect as sweat is an exception to the body fluids covered under standard precautions.
5. Which of the following actions is most appropriate when working with a client who is extremely angry?
- A. Place a light hand on the client's shoulder to convey understanding
- B. Maintain close proximity to build trust
- C. Temporarily change the subject if the client's behavior is escalating
- D. Close the door to the room to ensure privacy
Correct answer: Temporarily change the subject if the client's behavior is escalating
Rationale: When dealing with an angry client, it is crucial to employ techniques that can help de-escalate the situation or ensure safety while providing care. If the client's behavior is escalating or they are fixating on a particular topic that is fueling their anger, it is advisable to temporarily change the subject. This technique can serve as a distraction from the initial trigger, allowing the client to refocus their thoughts and emotions. Placing a hand on the client's shoulder may not be well-received as physical touch can escalate the situation. Maintaining close proximity might be perceived as confrontational rather than building trust. Closing the door for privacy is important but may not directly address the client's anger or help in de-escalation.
Similar Questions
Access More Features
NCLEX Basic
- 5,000 Questions with answers
- Comprehensive NCLEX coverage
- 30 days access @ $69.99
NCLEX Basic
- 5,000 Questions and answers
- Comprehensive NCLEX Coverage
- 90 days access @ $69.99