NCLEX NCLEX-RN
NCLEX RN Prioritization Questions
1. The nurse caring for Mrs. J is prepared to suction her endotracheal tube. Which of the following interventions will reduce hypoxia during this procedure?
- A. Hyperoxygenate Mrs. J for up to 60 seconds prior to starting
- B. Administer 15 mL of sterile fluid into the tube prior to suctioning
- C. Suction for no longer than 30 seconds at a time
- D. Wait 30 seconds after suctioning before attempting again
Correct answer: Hyperoxygenate Mrs. J for up to 60 seconds prior to starting
Rationale: Before suctioning a client's endotracheal tube, it is essential to hyperoxygenate the client for approximately 30 to 60 seconds. Hyperoxygenation helps increase oxygen delivery to the tissues, reducing the risk of hypoxia during and after the suctioning procedure. Administering fluid into the tube before suctioning (Choice B) is unnecessary and can lead to complications. Suctioning for no longer than 30 seconds at a time (Choice C) is a general guideline but does not specifically address reducing hypoxia. Waiting 30 seconds after suctioning before attempting again (Choice D) may lead to inadequate oxygenation and potential hypoxia, making it less effective in preventing this complication compared to hyperoxygenation prior to suctioning.
2. Why is it important for the nurse to inform the family about the client's situation?
- A. To decrease the client's anxiety
- B. To help the family better adapt to necessary role changes
- C. To improve communication between family and nursing staff
- D. To ensure a more relaxed atmosphere for the client
Correct answer: To help the family better adapt to necessary role changes
Rationale: It is crucial for the nurse to inform the family about the client's situation to help them better adapt to necessary role changes. By providing early notification, the family can start preparing for potential adjustments. While reducing the client's anxiety and improving communication with the nursing staff are important, the primary purpose is to assist the family in undertaking the required role changes. Creating a relaxed atmosphere for the client, although beneficial, is not the main objective in this situation.
3. What action will the nurse plan to take for a 40-year-old patient with multiple sclerosis (MS) who has urinary retention caused by a flaccid bladder?
- A. Decrease the patient's evening fluid intake.
- B. Teach the patient how to use the Cred method.
- C. Suggest the use of adult incontinence briefs for nighttime only.
- D. Assist the patient to the commode every 2 hours during the day.
Correct answer: Teach the patient how to use the Cred method.
Rationale: For a 40-year-old patient with multiple sclerosis experiencing urinary retention due to a flaccid bladder, teaching the Cred method is the appropriate action. The Cred method involves applying manual pressure over the bladder to aid in bladder emptying. Decreasing fluid intake is not the correct approach as it will not address the underlying issue of bladder emptying and may lead to dehydration and urinary tract infections. Using adult incontinence briefs only addresses the symptom of incontinence without addressing the bladder emptying problem. Assisting the patient to the commode every 2 hours does not actively address the issue of improving bladder emptying as effectively as teaching the Cred method.
4. OSHA has very strict standards for hospital employees who may encounter hazardous materials or patients who have been exposed to them. These regulations include all of the following EXCEPT:
- A. Respiratory protection must be provided to all employees who might be exposed.
- B. Training on respiratory protection must be provided.
- C. Employers must provide personal protective equipment to all employees.
- D. All ED personnel must be trained in decontamination procedures.
Correct answer: All ED personnel must be trained in decontamination procedures.
Rationale: OSHA regulations for hospital employees dealing with hazardous materials or exposed patients require respiratory protection for potentially exposed employees, training on respiratory protection, and the provision of personal protective equipment. However, not all ED personnel are required to be trained in decontamination procedures. While all ED staff should have a basic understanding of hazmat situations, specific training in decontamination procedures is only necessary for those who will be directly involved in the decontamination process. Therefore, the correct answer is that all ED personnel must be trained in decontamination procedures, as this is not a mandatory requirement under OSHA regulations for hospital employees who may encounter hazardous materials or exposed patients.
5. Which of the following clients have barriers to accessing healthcare?
- A. A 36-year-old client who must use a wheelchair for mobility
- B. A 44-year-old client who is visiting the United States on a visa from India
- C. An 81-year-old client who is unable to drive
- D. All of the above
Correct answer: All of the above
Rationale: All of the provided clients have barriers to accessing healthcare. Clients with physical limitations, such as the 36-year-old client using a wheelchair, may face challenges in mobility and accessing healthcare facilities. The 44-year-old client from India visiting the United States on a visa may encounter barriers related to language, cultural differences, or insurance coverage. The 81-year-old client who is unable to drive may struggle with transportation to healthcare appointments. Therefore, all three clients face different barriers to accessing healthcare, making 'All of the above' the correct answer.
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