NCLEX-RN
NCLEX RN Prioritization Questions
1. A patient with bacterial pneumonia has rhonchi and thick sputum. What is the nurse's most appropriate action to promote airway clearance?
- A. Assist the patient to splint the chest when coughing.
- B. Teach the patient about the need for fluid intake.
- C. Encourage the patient to wear the nasal oxygen cannula.
- D. Instruct the patient on the pursed lip breathing technique.
Correct answer: A
Rationale: Assisting the patient to splint the chest when coughing is the most appropriate action to promote airway clearance in a patient with bacterial pneumonia, rhonchi, and thick sputum. Splinting the chest helps reduce pain during coughing and increases the effectiveness of clearing secretions. Teaching the patient about the need for fluid intake is important as it helps liquefy secretions, aiding in easier clearance. Encouraging the patient to wear a nasal oxygen cannula may improve gas exchange but does not directly promote airway clearance. Instructing the patient on the pursed lip breathing technique is beneficial for improving gas exchange in patients with COPD but does not directly aid in airway clearance in a patient with bacterial pneumonia and thick sputum.
2. A child is suspected of suffering from intussusception. The nurse should be alert to which clinical manifestation of this condition?
- A. Tender, distended abdomen
- B. Presence of fecal incontinence
- C. Incomplete development of the anus
- D. Infrequent and difficult passage of dry stools
Correct answer: A
Rationale: Intussusception is an invagination of a section of the intestine into the distal bowel, and it is the most common cause of bowel obstruction in children aged 3 months to 6 years. A tender, distended abdomen is a typical clinical manifestation of intussusception. The presence of fecal incontinence is not a characteristic presentation of intussusception; it describes encopresis, which generally affects preschool and school-aged children but is not specific to intussusception. Incomplete development of the anus describes imperforate anus, a disorder diagnosed in the neonatal period, not intussusception. The infrequent and difficult passage of dry stools is characteristic of constipation, a common issue in children that can occur at any age, although it often peaks at 2 to 3 years old.
3. A nurse frequently treats patients in the 72-hour period after a stroke has occurred. The nurse would be most concerned about which of these assessment findings?
- A. INR is 3 seconds long
- B. Heart rate is 110 beats per minute
- C. Intracranial Pressure is 22 mmHg
- D. Blood pressure is 140/80
Correct answer: C
Rationale: The nurse would be most concerned about the assessment finding of an Intracranial Pressure (ICP) reading of 22 mmHg in a patient 72 hours post-stroke. Elevated ICP can indicate increased risk of edema and further brain damage. A target ICP should ideally be maintained at less than or equal to 15-20 mmHg. While the other options may also be important to monitor, an elevated ICP poses a more immediate threat to the patient's neurological status and requires prompt attention.
4. A patient has been taking mood stabilizing medication but is afraid of needles. They ask the nurse what medication would NOT require regular lab testing. What is the nurse's best response?
- A. Valproic Acid (Depakote)
- B. Clozapine (Clozaril)
- C. Lithium
- D. Risperidone (Risperdal)
Correct answer: D
Rationale: The correct answer is Risperidone (Risperdal) because it is the only medication among the options that does not require regular lab testing. Risperidone is not associated with the need for routine blood draws to monitor medication levels or potential side effects. Choices A, B, and C (Valproic Acid, Clozapine, Lithium) are all known to require frequent lab monitoring due to various reasons such as potential toxicity, therapeutic drug levels, or adverse effects on certain organ functions. Therefore, considering the patient's fear of needles and the desire to avoid frequent blood tests, Risperidone would be the most suitable option.
5. The mother of a child with hepatitis A tells the home care nurse that she is concerned because the child's jaundice seems worse. What is the nurse's best response?
- A. You need to change the child's diet.
- B. The child probably is infectious again.
- C. The jaundice may worsen before it resolves.
- D. You need to call the primary health care provider.
Correct answer: C
Rationale: The best response for the nurse in this situation is to explain to the mother that jaundice may seem to worsen before it eventually gets better. This is a common occurrence in hepatitis A. Option A about changing the child's diet is irrelevant to the concern raised by the mother and not supported by evidence. Option B suggesting the child is infectious again is incorrect and may cause unnecessary alarm as jaundice does not indicate reinfection. Option D, advising the mother to call the primary health care provider, is premature as the nurse can first provide education and reassurance regarding the expected course of jaundice in hepatitis A.
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