NCLEX RN Prioritization Questions - Nurselytic

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NCLEX RN Prioritization Questions Questions

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Question 1 of 5

One hour after a thoracotomy, a patient complains of incisional pain at a level 7 (based on a 0 to 10 scale) and has decreased left-sided breath sounds. The pleural drainage system has 100 mL of bloody drainage and a large air leak. Which action is best for the nurse to take next?

Correct Answer: S

Rationale: In this scenario, the best action is to set up the patient-controlled analgesia (PC
A) and administer the loading dose of morphine. The patient's pain level is high, which can hinder deep breathing and coughing. Addressing pain control is a priority to facilitate optimal respiratory function. Milking the chest tube to remove clots is unnecessary as the drainage amount is not alarming in the early postoperative period. Clamping the chest tube to locate the air leak is not recommended as it can lead to tension pneumothorax. Assisting the patient to deep breathe, cough, and use the incentive spirometer is important but should follow adequate pain management to ensure the patient can effectively participate in these activities.

Question 2 of 5

Correct Answer:

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Question 3 of 5

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Question 4 of 5

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Question 5 of 5

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