NCLEX-RN
NCLEX RN Prioritization Questions
1. A patient has just been admitted with probable bacterial pneumonia and sepsis. Which order should the nurse implement first?
- A. Performing a chest x-ray via stretcher
- B. Obtaining blood cultures from two sites
- C. Administering Ciprofloxacin (Cipro) 400 mg IV
- D. Inserting an Acetaminophen (Tylenol) rectal suppository
Correct answer: B
Rationale: In a patient with probable bacterial pneumonia and sepsis, the priority intervention is to obtain blood cultures from two sites before initiating antibiotic therapy. This is crucial to identify the causative organism and guide appropriate antibiotic treatment. Administering antibiotics without obtaining cultures first can interfere with accurate results. Performing a chest x-ray and administering acetaminophen can be done after obtaining blood cultures as they are important but not as urgent as identifying the causative organism in sepsis.
2. Which of the following can cause coup-contrecoup injuries?
- A. Rotational forces
- B. Deformation forces
- C. Deceleration forces
- D. Acceleration forces
Correct answer: C
Rationale: Deceleration forces occur when the head is moving and abruptly comes to a stop, such as in a car crash. This sudden deceleration can cause the brain to hit against the skull, resulting in coup-contrecoup injuries. In a coup-contrecoup injury, the brain is damaged on opposite sides due to the initial impact and the rebound effect inside the skull. Rotational forces usually result in diffuse axonal injuries rather than coup-contrecoup injuries. Deformation forces can cause focal brain injuries but not coup-contrecoup injuries. Acceleration forces typically lead to diffuse brain injuries, not coup-contrecoup injuries. Therefore, the correct answer is deceleration forces.
3. The nurse is caring for an infant with cryptorchidism. The nurse anticipates that the most likely diagnostic study to be prescribed would be the one that assesses which item?
- A. Babinski reflex
- B. DNA synthesis
- C. Urinary function
- D. Chromosomal analysis
Correct answer: C
Rationale: Cryptorchidism, also known as undescended testes, may be caused by hormonal deficiency, intrinsic testicular abnormality, or a structural problem. Diagnostic studies for cryptorchidism typically involve assessing urinary function because the kidneys and testes originate from the same embryonic tissue. The Babinski reflex is a test for neurological function and is not relevant to evaluating cryptorchidism. DNA synthesis and chromosomal analysis are not commonly used diagnostic tests for cryptorchidism, as they are unrelated to the disorder's etiology or presentation.
4. 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.
5. A healthcare professional is reviewing a patient's chart and notices that the patient suffers from Lyme disease. Which of the following microorganisms is related to this condition?
- A. Borrelia burgdorferi
- B. Streptococcus pyogenes
- C. Bacillus anthracis
- D. Enterococcus faecalis
Correct answer: A
Rationale: Lyme disease, the most common vector-borne disease in the United States, is caused by the bacterium Borrelia burgdorferi. Borrelia burgdorferi is transmitted to humans through the bite of infected black-legged ticks. Streptococcus pyogenes is associated with strep throat and other infections, not Lyme disease. Bacillus anthracis causes anthrax, a separate infectious disease. Enterococcus faecalis is more commonly linked to urinary tract infections and other healthcare-associated infections, not Lyme disease.
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