NCLEX-RN
NCLEX RN Prioritization Questions
1. The patient with idiopathic pulmonary arterial hypertension (IPAH) is receiving epoprostenol (Flolan). Which assessment information requires the most immediate action by the nurse?
- A. The oxygen saturation is 94%.
- B. The blood pressure is 98/56 mm Hg.
- C. The patient's central IV line is disconnected.
- D. The international normalized ratio (INR) is prolonged.
Correct answer: C
Rationale: The most immediate action required by the nurse is to address the disconnected central IV line delivering epoprostenol (Flolan). Epoprostenol has a short half-life of 6 minutes, necessitating immediate reconnection to prevent rapid clinical deterioration. While oxygen saturation, blood pressure, and INR are important parameters requiring monitoring and intervention, the priority lies in ensuring the continuous delivery of the critical medication to stabilize the patient's condition.
2. Which of the following diseases is caused by the Bordetella pertussis bacterium?
- A. German Measles
- B. RSV
- C. Meningitis
- D. Whooping Cough
Correct answer: D
Rationale: Bordetella pertussis is the bacterium responsible for causing Whooping Cough, also known as pertussis. Meningitis can be caused by various bacteria, but not specifically by Bordetella pertussis. German Measles, also known as Rubella, and RSV (Respiratory Syncytial Virus) are viral infections and are not caused by the Bordetella pertussis bacterium. Therefore, the correct answer is Whooping Cough, caused by Bordetella pertussis.
3. Based on Mr. C's assessment, which of the following nursing interventions is most appropriate?
- A. Elevate the lower extremities to 45 degrees to promote venous return
- B. Place Mr. C in the Trendelenburg position
- C. Administer total parenteral nutrition
- D. Monitor urine output
Correct answer: D
Rationale: In the context of Mr. C's assessment, the most appropriate nursing intervention is to monitor urine output. A client in hypovolemic shock may experience decreased urine output due to poor kidney perfusion. By monitoring urine output, the nurse can assess renal function and fluid status. Administering total parenteral nutrition (Choice C) is not indicated based on the information provided, as the priority is to stabilize the client's condition. Elevating the lower extremities (Choice A) may be helpful in some cases but is not the priority in this situation. Placing Mr. C in the Trendelenburg position (Choice B) is contraindicated in hypovolemic shock as it can worsen venous return and compromise cardiac output.
4. Following surgery to correct cryptorchidism, what is the priority action that the nurse should include in the plan of care?
- A. Prevent tension on the suture.
- B. Monitor urine for glucose and acetone.
- C. Encourage oral fluids, and monitor intake and output.
- D. Encourage coughing and deep breathing every hour.
Correct answer: A
Rationale: The correct answer is to prevent tension on the suture. After surgery for cryptorchidism, the testicle is held in position by an internal suture that should not be dislodged. Immobilization of the area for a week is crucial to prevent complications like bleeding and infection. Monitoring urine for glucose and acetone is unrelated to this surgery. While maintaining hydration is important, forcing fluids is not necessary. Encouraging coughing and deep breathing every hour may be a postoperative consideration, but it is not the priority for this specific surgery.
5. Which of the following glands found in the skin secretes a liquid called Sebum?
- A. Apocrine Glands
- B. Sebaceous Glands
- C. Lacrimal Glands
- D. Sweat Glands
Correct answer: B
Rationale: Sebum is a liquid secreted by glands in the skin known as sebaceous glands. Sebum's primary function is to lubricate the skin and help maintain its integrity. Apocrine glands secrete a different type of sweat that is odorless but can develop an odor when combined with bacteria on the skin. Lacrimal glands produce tears to keep the eyes moist, and sweat glands secrete sweat to regulate body temperature through evaporation. Therefore, the correct answer is Sebaceous Glands because they specifically secrete sebum, distinguishing them from the other gland types mentioned.
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