NCLEX-RN
NCLEX RN Prioritization Questions Questions
Question 1 of 9
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.
Question 2 of 9
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.
Question 3 of 9
The patient is being taught about pulmonary function testing (PFT). Which statement made by the patient indicates effective teaching?
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.
Question 4 of 9
A client is found unresponsive in his room by a nurse. The client is not breathing and does not have a pulse. After calling for help, what is the next action the nurse should take?
Correct Answer: C
Rationale: After finding an unresponsive client who is not breathing and has no pulse, the nurse's immediate action should be to call for help and start chest compressions. Chest compressions should be initiated at a rate of at least 100 per minute and a depth of at least 2 inches. Choice A, administering ventilations, is not the initial step as compressions take priority. Choice B, performing a head-tilt, chin lift, is also not the first step; chest compressions are crucial before airway management. Choice D, performing a jaw thrust, is typically used in cases of suspected cervical spine injury and is not the immediate action in this scenario.
Question 5 of 9
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?
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.
Question 6 of 9
In which order should the nurse take the following actions for an older patient with new onset confusion who is normally alert and oriented?
Correct Answer: B
Rationale: The correct order of actions for the nurse in this scenario is to first obtain the oxygen saturation to assess the patient's airway and oxygenation status. Next, checking the patient's pulse rate helps in evaluating circulation. Subsequently, documenting the change in the patient's status is important for maintaining an accurate record of care. Finally, notifying the health care provider is crucial to ensure timely intervention and further management. Choices A, C, and D are incorrect because assessing oxygen saturation should precede checking the pulse rate to address potential physiological causes of confusion. Additionally, documentation should follow patient assessment and notification of the healthcare provider for appropriate record-keeping and communication.
Question 7 of 9
The health care provider writes an order for bacteriologic testing for a patient who has a positive tuberculosis skin test. Which action should the nurse take?
Correct Answer: C
Rationale: The correct action for the nurse to take is to teach the patient about the need to collect sputum specimens for 2 to 3 consecutive days for bacteriologic testing for M. tuberculosis. It is important to obtain these specimens on different days rather than all at once. Blood tests are not used for tuberculosis testing, so teaching about blood tests is not relevant. While a chest x-ray is important in tuberculosis diagnosis, it is not a bacteriologic test. The appearance on a chest x-ray alone is not sufficient to diagnose TB as other diseases can have similar findings.
Question 8 of 9
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?
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.
Question 9 of 9
A nurse is caring for a patient with peripheral vascular disease (PVD). The patient complains of burning and tingling of the hands and feet and cannot tolerate touch of any kind. Which of the following is the most likely explanation for these symptoms?
Correct Answer: A
Rationale: Patients with the peripheral vascular disease often sustain nerve damage as a result of inadequate tissue perfusion. Ischemic rest pain is more worrisome; it refers to pain in the extremity that is due to a combination of PVD and inadequate perfusion. Ischemic rest pain often is exacerbated by poor cardiac output. The condition is often partially or fully relieved by placing the extremity in a dependent position, so that perfusion is enhanced by the effects of gravity.