NCLEX-RN
NCLEX RN Exam Questions Questions
Question 1 of 5
Which goal has the highest priority in the plan of care for a 26-year-old homeless patient admitted with viral hepatitis who has severe anorexia and fatigue?
Correct Answer: B
Rationale: The highest priority outcome is to maintain adequate nutrition because it is essential for hepatocyte regeneration. In viral hepatitis, the liver is affected, and proper nutrition supports the liver's function and regeneration. While increasing activity level and establishing a stable environment are important, they are not as urgent as ensuring the patient receives proper nutrition. Identifying sources of hepatitis exposure can help prevent future infections, but in the acute phase, the immediate focus should be on providing adequate nutrition to support the patient's recovery.
Question 2 of 5
The nurse is planning care for a 48-year-old woman with acute severe pancreatitis. The highest priority patient outcome is
Correct Answer: A
Rationale: In acute severe pancreatitis, there is a risk of respiratory failure as a complication, making the maintenance of normal respiratory function the priority outcome. This patient may develop respiratory issues due to the inflammatory process affecting the diaphragm. While pain control, absence of ongoing pancreatic disease, and fluid/electrolyte balance are crucial, they are secondary to ensuring adequate oxygenation and ventilation to prevent respiratory compromise.
Question 3 of 5
The nurse is caring for a 36-year-old patient with pancreatic cancer. Which nursing action is the highest priority?
Correct Answer: C
Rationale: The correct answer is to administer prescribed opioids to relieve pain as needed. Pain management is the highest priority in this scenario as effective pain control is essential for the patient's overall well-being. Pain relief will not only improve the patient's comfort but also enhance their ability to eat, follow dietary recommendations, and be open to psychological support. Offering psychological support for depression (Choice A) is important but addressing pain takes precedence. While providing high-calorie, high-protein dietary choices (Choice B) is crucial, it is secondary to managing pain. Teaching about the need to avoid scratching pruritic areas (Choice D) is relevant but not the highest priority in this situation where pain management is critical for the patient's quality of life.
Question 4 of 5
Which assessment information will be most important for the nurse to report to the healthcare provider about a patient with acute cholecystitis?
Correct Answer: B
Rationale: The correct answer is that the patient's stools are tan colored. Tan or grey stools indicate biliary obstruction, which requires rapid intervention to resolve in a patient with acute cholecystitis. This change in stool color is a critical sign that the healthcare provider needs to be informed about promptly. The other choices are less concerning and may be common symptoms in patients with acute cholecystitis, but tan-colored stools specifically indicate a potential serious complication that warrants immediate attention.
Question 5 of 5
Which action will the nurse include in the plan of care for a patient who has been diagnosed with chronic hepatitis B?
Correct Answer: B
Rationale: Patients diagnosed with chronic hepatitis B are at a higher risk for developing liver cancer. Therefore, it is essential to schedule them for liver cancer screening every 6 to 12 months to detect any potential malignancies at an early stage. Advising patients to limit alcohol intake is crucial as alcohol can exacerbate liver damage; thus, patients with chronic hepatitis B are advised to completely avoid alcohol. Administering the hepatitis C vaccine is irrelevant for a patient diagnosed with chronic hepatitis B since it is a different virus. Monitoring anti-hepatitis B surface antigen (anti-HBs) levels annually is not necessary as the presence of anti-HBs indicates a past hepatitis B infection or vaccination, and it does not require regular monitoring.