NCLEX-RN
NCLEX RN Prioritization Questions Questions
Question 1 of 5
The nurse assesses the chest of a patient with pneumococcal pneumonia. Which finding would the nurse expect?
Correct Answer: A
Rationale: Increased tactile fremitus over the area of pulmonary consolidation is expected with bacterial pneumonias, such as pneumococcal pneumonia. Dullness to percussion would be expected due to consolidation. Pneumococcal pneumonia typically presents with a loose, productive cough rather than a dry, nonproductive cough. Hyperresonance to percussion is not a typical finding in pneumonia and may suggest conditions like emphysema. Adventitious breath sounds such as crackles and wheezes are typical in pneumonia, but a grating sound on auscultation is more representative of a pleural friction rub rather than pneumonia.
Question 2 of 5
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?
Correct Answer: C
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.
Question 3 of 5
The nurse develops a plan of care to prevent aspiration in a high-risk patient. Which nursing action will be most effective?
Correct Answer: B
Rationale: To prevent aspiration in a high-risk patient, the most effective nursing action is to place patients with altered consciousness in side-lying positions. This position helps decrease the risk of aspiration as it prevents pooling of secretions and facilitates drainage. Turning and repositioning immobile patients every 2 hours is essential for preventing pressure ulcers and improving circulation but does not directly address the risk of aspiration. Monitoring respiratory symptoms in immunosuppressed patients is crucial to detect pneumonia early, but it does not directly prevent aspiration. Inserting a nasogastric tube for feedings in patients with swallowing problems may be necessary for nutritional support but does not address the risk of aspiration directly. Patients at high risk for aspiration include those with altered consciousness, difficulty swallowing, and those with nasogastric intubation, among others. Placing patients with altered consciousness in a side-lying position is a key intervention to reduce the risk of aspiration in this population. Other high-risk groups for aspiration include those who are seriously ill, have poor dentition, or are on acid-reducing medications.
Question 4 of 5
A patient with right lower-lobe pneumonia has been treated with IV antibiotics for 3 days. Which assessment data obtained by the nurse indicates that the treatment has been effective?
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Question 5 of 5
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.