NCLEX-RN
NCLEX RN Prioritization Questions Questions
Question 1 of 5
The patient with idiopathic pulmonary arterial hypertension (IPAH) is receiving epoprostenol (Flolan). Which assessment information requires the most immediate action by the nurse?
Correct Answer: C
Rationale: The most immediate action required by the nurse is to address the disconnected central IV line delivering epoprostenol (Flolan). Epoprostenol has a short half-life of 6 minutes, necessitating immediate reconnection to prevent rapid clinical deterioration. While oxygen saturation, blood pressure, and INR are important parameters requiring monitoring and intervention, the priority lies in ensuring the continuous delivery of the critical medication to stabilize the patient's condition.
Question 2 of 5
A patient has acute bronchitis with a nonproductive cough and wheezes. Which topic should the nurse plan to include in the teaching plan?
Correct Answer: C
Rationale: In acute bronchitis, which is often viral, cough suppressants can help manage the symptoms of a nonproductive cough. Antibiotics are not typically used in acute bronchitis unless there are systemic symptoms indicating a bacterial infection. Limiting oral fluid intake is not recommended; in fact, maintaining adequate hydration is important. Safety concerns with home oxygen therapy may not be directly relevant to the management of acute bronchitis.
Question 3 of 5
Which intervention will the nurse include in the plan of care for a patient diagnosed with a lung abscess?
Correct Answer: D
Rationale: For a patient diagnosed with a lung abscess, the priority intervention is to educate them about the importance of prolonged antibiotic therapy post-hospital discharge. Long-term antibiotic treatment is crucial for eradicating the infecting organisms in a lung abscess. Chest physiotherapy and postural drainage are not recommended for lung abscess as they can potentially spread the infection. While foul-smelling and bloody sputum are common in lung abscess, immediate notification to the healthcare provider is essential. Avoiding the use of over-the-counter expectorants is not necessary, as expectorants can be used to facilitate coughing and clearing of secretions in this condition.
Question 4 of 5
The patient who has two fractured ribs from an automobile accident is receiving discharge teaching. Which statement by the patient indicates effective teaching?
Correct Answer: D
Rationale: The correct answer is, 'I will use the incentive spirometer every hour or two during the day.' After sustaining rib fractures, it is crucial to prevent complications like atelectasis and pneumonia by practicing deep breathing and coughing. Using the incentive spirometer helps in maintaining lung expansion and preventing respiratory issues. Buying a rib binder could restrict chest expansion and hinder deep breathing efforts, increasing the risk of atelectasis. Taking shallow breaths may not effectively expand the lungs, leading to potential respiratory complications. Relying solely on pain medication at bedtime may not adequately address the need for lung expansion and prevention of respiratory complications during the day.
Question 5 of 5
Which factors will the nurse consider when calculating the CURB-65 score for a patient with pneumonia? (Select one that does not apply)
Correct Answer: D
Rationale: The correct answer is 'Oxygen saturation.' When calculating the CURB-65 score for a patient with pneumonia, the factors considered include mental status (confusion), BUN (elevated), blood pressure (decreased), respiratory rate (increased), and age (65 and older). Oxygen saturation is not used in the CURB-65 scoring system. While blood pressure, respiratory rate, and age are factors that are used in the calculation of the CURB-65 score, oxygen saturation is not part of the scoring criteria. Therefore, oxygen saturation is the factor that does not apply when calculating the CURB-65 score.