NCLEX RN Prioritization Questions

NCLEX RN Prioritization Questions Related

Review NCLEX RN Prioritization Questions related questions and content

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?

  • A. The patient is offered a tissue from the box at the bedside.
  • B. A surgical face mask is applied before visiting the patient.
  • C. A snack is brought to the patient from the unit refrigerator.
  • D. Hand washing is performed before entering the patient's room.
Correct Answer: B

Rationale: When caring for a patient with active tuberculosis (TB), it is crucial to use a high-efficiency particulate-absorbing (HEPA) mask instead of a standard surgical mask when entering the patient's room, as a HEPA mask can filter out 100% of small airborne particles, reducing the risk of transmission. Therefore, if the student nurse applies only a surgical face mask before visiting the patient, this action would require intervention by the nurse to ensure the appropriate protective equipment is used. Hand washing before entering the patient's room is essential to prevent the spread of infection and is a correct action. Bringing a snack to the patient from the unit refrigerator is appropriate and helps address potential issues with anorexia and weight loss in patients with TB. While hand washing after handling a tissue used by the patient is necessary, no special precautions are required when offering the patient an unused tissue.

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The nurse notes that a patient has incisional pain, a poor cough effort, and scattered rhonchi after a thoracotomy. Which action should the nurse take first?

  • A. Assist the patient to sit upright in a chair.
  • B. Splint the patient's chest during coughing.
  • C. Medicate the patient with prescribed morphine.
  • D. Observe the patient use the incentive spirometer.
Correct Answer: C

Rationale: The correct answer is to medicate the patient with prescribed morphine. A major reason for atelectasis and poor airway clearance in patients after chest surgery is incisional pain, which can worsen with deep breathing and coughing. The priority is to address the incisional pain to facilitate effective coughing and deep breathing, which are essential for clearing the airways and preventing complications. Assisting the patient to sit upright, splinting the patient's chest during coughing, and observing the patient using the incentive spirometer are all appropriate interventions to improve airway clearance, but they should be implemented after addressing the incisional pain with medication.

When auscultating the patient's lungs during a shift assessment on a patient admitted in the early phase of heart failure, which finding would the nurse most likely hear?

  • A. Continuous rumbling, snoring, or rattling sounds mainly on expiration
  • B. Continuous high-pitched musical sounds on inspiration and expiration
  • C. Discontinuous, high-pitched sounds of short duration heard on inspiration
  • D. A series of long-duration, discontinuous, low-pitched sounds during inspiration
Correct Answer: C

Rationale: In the early phase of heart failure, fine crackles are likely to be heard upon auscultation of the lungs. Fine crackles are characterized as discontinuous, high-pitched sounds of short duration heard on inspiration. Rhonchi are continuous rumbling, snoring, or rattling sounds mainly on expiration, which are often associated with airway secretions. Coarse crackles are a series of long-duration, discontinuous, low-pitched sounds during inspiration, typically indicating fluid in the alveoli. Wheezes are continuous high-pitched musical sounds on inspiration and expiration, commonly heard in conditions like asthma or chronic obstructive pulmonary disease (COPD). Therefore, the correct choice is C, as it describes the expected lung sounds in a patient with early heart failure.

The patient is being taught about pulmonary function testing (PFT). Which statement made by the patient indicates effective teaching?

  • A. I will use my inhaler right before the test.
  • B. I won't eat or drink anything 8 hours before the test.
  • C. I should inhale deeply and blow out as hard as I can during the test.
  • D. My blood pressure and pulse will be checked every 15 minutes after the test.
Correct Answer: C

Rationale: The correct answer is 'I should inhale deeply and blow out as hard as I can during the test.' This statement indicates effective teaching because for PFT, the patient needs to inhale deeply and exhale forcefully. This maneuver helps in assessing lung function accurately. Choices A, B, and D are incorrect. Using an inhaler right before the test may alter the test results, which is not recommended. Fasting for 8 hours is not necessary for a PFT, and checking blood pressure and pulse every 15 minutes after the test is not part of the PFT procedure.

A 64-year-old patient with amyotrophic lateral sclerosis (ALS) is hospitalized with pneumonia. Which nursing action will be included in the plan of care?

  • A. Assist with active range of motion (ROM).
  • B. Observe for agitation and paranoia.
  • C. Give muscle relaxants as needed to reduce spasms.
  • D. Use simple words and phrases to explain procedures.
Correct Answer: A

Rationale: In a patient with ALS, progressive muscle weakness is a significant issue. Assisting with active range of motion (ROM) exercises will help maintain muscle strength for as long as possible. Agitation and paranoia are not typically associated with ALS, making choice B incorrect. Giving muscle relaxants can further weaken muscles and depress respirations, worsening the condition, so choice C is inappropriate. Choice D is not directly related to the patient's physical condition and needs.

A patient with stage I nonsmall cell lung cancer expresses a preference for chemotherapy over surgery. Which response by the nurse is most appropriate?

  • A. Are you concerned about the potential pain from surgery?
  • B. Have you had negative experiences with previous surgeries?
  • C. Surgery is the recommended treatment for stage I lung cancer.
  • D. Tell me about your understanding of the different available treatments.
Correct Answer: D

Rationale: The most appropriate response by the nurse in this situation is to gather more information about the patient's concerns and preferences. By asking the patient to share their understanding of the available treatments, the nurse encourages open communication and gains insight into the patient's knowledge and preferences. Option A focuses solely on pain, which may not be the patient's primary concern. Option B assumes negative experiences without exploring the patient's current thoughts. Option C, stating that surgery is the recommended treatment, dismisses the patient's preference and does not address their concerns. Chemotherapy is not the primary treatment for nonsmall cell lung cancer; it may be used for nonresectable tumors or as adjuvant therapy to surgery, making it crucial for the nurse to explore the patient's treatment preferences and understanding.

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