the nurse plans health care for a community with a large number of recent immigrants from vietnam which intervention is the most important for the nur
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Nursing Elites

NCLEX-RN

NCLEX RN Prioritization Questions

1. The nurse plans health care for a community with a large number of recent immigrants from Vietnam. Which intervention is the most important for the nurse to implement?

Correct answer: B

Rationale: Tuberculosis (TB) is prevalent in many parts of Asia, including Vietnam, and the incidence of TB is higher in immigrants from Vietnam compared to the general U.S. population. Conducting tuberculosis screening is crucial to identify and address any cases promptly, especially in a community with recent immigrants from Vietnam. While teaching about contraceptive use, providing colonoscopy information, and testing for hepatitis may be relevant for certain individuals in the community, they are not as universally important as tuberculosis screening due to the increased risk of TB among Vietnamese immigrants.

2. A patient asks a nurse administering blood how long red blood cells live in the body. What is the correct response?

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.

3. Following assessment of a patient with pneumonia, the nurse identifies a nursing diagnosis of ineffective airway clearance. Which assessment data best supports this diagnosis?

Correct answer: A

Rationale: The correct answer is 'Weak, nonproductive cough effort.' A weak, nonproductive cough indicates that the patient is unable to clear the airway effectively, supporting the nursing diagnosis of ineffective airway clearance. In pneumonia, secretions can obstruct the airway, leading to ineffective clearance. Choices B, C, and D do not directly reflect ineffective airway clearance. Large amounts of greenish sputum (Choice B) may suggest infection or inflammation but do not specifically indicate ineffective airway clearance. The respiratory rate of 28 breaths/minute (Choice C) and a resting pulse oximetry (SpO2) of 85% (Choice D) are more indicative of impaired gas exchange or respiratory distress rather than ineffective airway clearance.

4. Using the illustrated technique, the healthcare provider is assessing for which finding in a patient with chronic obstructive pulmonary disease (COPD)?

Correct answer: D

Rationale: The technique for palpation for chest expansion is shown in the illustrated technique. Reduced chest expansion would be noted on palpation of a patient's chest with COPD. Hyperresonance would be assessed through percussion, not palpation. Accessory muscle use and tripod positioning would be assessed by inspection, not palpation.

5. Administration of hepatitis B vaccine to a healthy 18-year-old patient has been effective when a specimen of the patient's blood reveals

Correct answer: B

Rationale: The correct answer is 'anti-HBs'. The presence of surface antibody to HBV (anti-HBs) indicates a successful response to the hepatitis B vaccine. Anti-HBs is a marker of immunity and protection against hepatitis B infection. Choices A, C, and D are incorrect because: A) HBsAg indicates current infection with hepatitis B virus, C) anti-HBc IgG suggests past infection or immunity, and D) anti-HBc IgM is a marker of acute hepatitis B infection.

Similar Questions

When caring for a patient hospitalized with active tuberculosis (TB), the nurse observes a student nurse who is assigned to take care of the patient. Which action, if performed by the student nurse, would require an intervention by the nurse?
Which of these findings indicate that a pump to deliver a basal rate of 10 ml per hour plus PRN for pain breakthrough for a morphine drip is not working?
Which of the following diseases or disorders is acute?
A healthcare professional has just received a medication order that is not legible. Which statement best reflects assertive communication?
The nurse assesses the chest of a patient with pneumococcal pneumonia. Which finding would the nurse expect?

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