a patient with newly diagnosed lung cancer tells the nurse i dont think im going to live to see my next birthday which response by the nurse is best
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Nursing Elites

NCLEX-RN

NCLEX RN Prioritization Questions

1. A patient with newly diagnosed lung cancer tells the nurse, 'I don't think I'm going to live to see my next birthday.' Which response by the nurse is best?

Correct answer: B

Rationale: The nurse's initial response should be to collect more assessment data about the patient's statement. The answer beginning 'Can you tell me what it is' is the most open-ended question and will offer the best opportunity for obtaining more data. The answer beginning 'Are you afraid' implies that the patient thinks that the cancer will be immediately fatal, although the patient's statement may not be related to the cancer diagnosis. The remaining two answers offer interventions that may be helpful to the patient, but more assessment is needed to determine whether these interventions are appropriate.

2. Diabetic patients are more prone to ____________ than other people without this chronic disorder.

Correct answer: A

Rationale: Diabetic patients are more prone to infection than other people without this chronic disorder. Diabetes weakens the immune system and impairs the body's ability to fight off infections, making individuals with diabetes more susceptible to various types of infections. Increased oxygen saturation, low fibrinogen, and constipation are not directly related to diabetes or the increased infection risk associated with the condition. Increased oxygen saturation is actually a positive health indicator, low fibrinogen levels are not a common issue in diabetes, and constipation is not a primary concern when comparing diabetic patients to others without the condition.

3. Which of the following interventions should the nurse use when working with a Jackson-Pratt drain?

Correct answer: C

Rationale: A Jackson-Pratt drain is a type of active wound drain that may be placed following a surgical procedure. This drain actively draws excess blood and fluid out of the wound. If clots develop within the tubing, the nurse should strip the tubing by milking it in a direction away from the client. This action helps to ensure the drain remains patent and effective. Option A is incorrect because the tubing should be milked away from the client, not towards. Option B is incorrect as the drain should be emptied based on the healthcare provider's orders, not at a fixed volume. Option D is incorrect because the level of the drain should be below the level of the incision to allow drainage by gravity.

4. The nurse is caring for a client with a serum potassium level of 3.5 mEq/L. The client is placed on a cardiac monitor and receives 40 mEq potassium chloride in 1000 ml of 5% dextrose in water IV. Which of the following EKG patterns indicates to the nurse that the infusions should be discontinued?

Correct answer: C

Rationale: A tall peaked T wave is a characteristic EKG pattern associated with hyperkalemia. Hyperkalemia refers to high levels of potassium in the blood, which can lead to cardiac arrhythmias and other serious complications. Tall peaked T waves are a red flag for potential cardiac issues and can indicate the need to discontinue potassium infusions. The other choices, such as narrowed QRS complex, shortened "PR"? interval, and prominent "U"? waves, are not typically associated with hyperkalemia. Therefore, recognizing tall peaked T waves is crucial for the nurse to take prompt action in managing the client's condition.

5. The home health nurse visits a male client to provide wound care and finds the client lethargic and confused. His wife states he fell down the stairs two (2) hours ago. The nurse should

Correct answer: B

Rationale: In this scenario, the client is presenting with concerning symptoms of lethargy and confusion after a fall. These symptoms could indicate a serious underlying issue, such as a head injury or internal bleeding. The nurse's priority is to ensure the client receives immediate evaluation and treatment to prevent any further harm. Option B is the correct choice as it emphasizes the urgency of the situation. Choices A, C, and D are incorrect because they do not address the critical nature of the client's condition. Contacting the healthcare provider, reassuring the wife, or waiting for symptoms to worsen could delay necessary medical intervention.

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