NCLEX NCLEX-RN
NCLEX RN Prioritization Questions
1. The nurse provides discharge instructions to a patient who was hospitalized for pneumonia. Which statement, if made by the patient, indicates a good understanding of the instructions?
- A. I will call the doctor if I still feel tired after a week.
- B. I will continue to do the deep breathing and coughing exercises at home.
- C. I will continue to do the deep breathing and coughing exercises at home.
- D. I'll cancel my chest x-ray appointment if Im feeling better in a couple weeks
Correct answer: I will continue to do the deep breathing and coughing exercises at home.
Rationale: Patients should continue to cough and deep breathe after discharge. Fatigue is expected for several weeks. The Pneumovax and influenza vaccines can be given at the same time in different arms. Explain that a follow-up chest x-ray needs to be done in 6 to 8 weeks to evaluate resolution of pneumonia.
2. The rehabilitation nurse wishes to make the following entry into a client's plan of care: 'Client will reestablish a pattern of daily bowel movements without straining within two months.' The nurse would write this statement under which section of the plan of care?
- A. Nursing diagnosis/problem list
- B. Nursing orders
- C. Short-term goals
- D. Long-term goals
Correct answer: Long-term goals
Rationale: The correct answer is 'Long-term goals.' Long-term goals are designed to describe changes in client behavior expected over a time frame greater than one week. In this case, the goal of reestablishing a pattern of daily bowel movements without straining within two months falls under a long-term goal. Long-term goals are aimed at restoring normal functioning in a problem area and are beneficial for healthcare workers caring for the client across different settings. Choices A, B, and C are incorrect because nursing diagnosis/problem list, nursing orders, and short-term goals do not encompass the desired timeframe or level of expected change in this scenario.
3. What nursing intervention demonstrates that the nurse understands the priority nursing diagnosis when caring for oral cancer patients with extensive tumor involvement and/or a high amount of secretions?
- A. The nurse uses a pen pad to communicate with the patient
- B. The nurse provides oral care every 2 hours
- C. The nurse listens for bowel sounds every 4 hours
- D. The nurse suctions as needed and elevates the head of the bed
Correct answer: The nurse suctions as needed and elevates the head of the bed
Rationale: The correct answer is to suction as needed and elevate the head of the bed. This intervention is crucial for managing Ineffective Airway Clearance, which is the priority nursing diagnosis in oral cancer patients with extensive tumor involvement and/or a high amount of secretions. Suctioning helps clear secretions that may obstruct the airway, while elevating the head of the bed promotes optimal respiratory function. Providing oral care every 2 hours may be important for overall oral health but is not directly related to addressing the priority diagnosis. Listening for bowel sounds every 4 hours is more relevant to gastrointestinal assessment and not specific to managing airway clearance issues in oral cancer patients.
4. After 5 years of unprotected intercourse, a childless couple comes to the fertility clinic. The husband tells the nurse that his parents have promised to make a down payment on a house for them if his wife gets pregnant this year. Which response would the nurse provide?
- A. ''This must be very difficult for you with this added pressure.''
- B. ''Having a child is a decision you should make without your parents’ input.''
- C. ''You’re lucky. It’s nice that your parents are making such a generous offer.''
- D. ''Five years without a pregnancy is a long time. You were right to come to the fertility clinic.''
Correct answer: ''This must be very difficult for you with this added pressure.''
Rationale: The correct response acknowledges the emotional challenge the couple is facing due to the added pressure of the incentive from the husband's parents. By expressing empathy and understanding, the nurse encourages the couple to open up about their feelings and concerns. Choice B is not the best response as it dismisses the husband's situation and fails to address the emotional impact of the added pressure. Choice C focuses on the parents' offer rather than the couple's emotional state, which is not the primary concern in this situation. Choice D, mentioning the duration of infertility, may come across as insensitive and may hinder open communication by potentially making the couple feel judged or discouraged.
5. The healthcare professional needs to validate which of the following statements pertaining to an assigned client?
- A. The client has a hard, raised, red lesion on his right hand.
- B. A weight of 185 lbs. is recorded in the chart.
- C. The client reported an infected toe.
- D. The client's blood pressure is 124/70.
Correct answer: The client reported an infected toe.
Rationale: Validation is the process of confirming that data are actual and factual. Data that can be measured can be accepted as factual, as in options 1, 3, and 4. The weight, blood pressure, and physical appearance of a lesion can be objectively verified. However, option C, the client reporting an infected toe, requires the nurse to directly assess the client's toe to confirm the statement. This choice involves subjective data that needs to be validated through direct observation, making it the correct answer. Options A, B, and D provide data that can be measured objectively and verified without the need for further assessment.
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