NCLEX-RN
NCLEX RN Exam Questions Questions
Extract:
Question 1 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 2 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 3 of 5
A female patient with atrial fibrillation has the following lab results: Hemoglobin of 11 g/dl, a platelet count of 150,000, an INR of 2.5, and potassium of 2.7 mEq/L. Which result is critical and should be reported to the physician immediately?
Correct Answer: D
Rationale: The critical lab result that should be reported to the physician immediately in this case is the potassium level of 2.7 mEq/L. A potassium imbalance, especially in a patient with a history of dysrhythmia like atrial fibrillation, can be life-threatening and lead to cardiac distress. Low potassium levels (hypokalemia) can predispose the patient to dangerous arrhythmias, including worsening atrial fibrillation. Hemoglobin of 11 g/dl, platelet count of 150,000, and an INR of 2.5 are within acceptable ranges and not as immediately concerning as a low potassium level in this clinical context.
Question 4 of 5
A client is scheduled for an Intravenous Pyelogram (IVP). In order to prepare the client for this test, the nurse would:
Correct Answer: C
Rationale: The correct preparation for an Intravenous Pyelogram (IVP) involves administering a laxative to the client the evening before the examination. This is crucial to ensure adequate bowel preparation, which in turn allows for better visualization of the bladder and ureters during the procedure. An IVP is an x-ray exam that utilizes contrast material to evaluate the kidneys, ureters, and bladder, aiding in the diagnosis of conditions like blood in the urine or pain in the side or lower back. Administering a laxative helps in achieving optimal imaging quality, which is essential for accurate diagnosis and subsequent treatment planning.
Choice A is incorrect because maintaining a regular diet is not the standard preparation for an IVP.
Choice B is incorrect as fluid intake is not typically restricted for this procedure.
Choice D is incorrect as an IVP involves multiple x-rays to assess the urinary system, not just one of the abdomen.
Question 5 of 5
The nurse is caring for a 73-year-old man with cirrhosis. Which data obtained by the nurse during the assessment will be of most concern?
Correct Answer: B
Rationale: The most concerning data obtained by the nurse is the patient's hands flapping back and forth when the arms are extended, indicating asterixis, which is associated with hepatic encephalopathy. This condition can progress to hepatic coma and requires immediate attention. The presence of spider angiomas and right upper-quadrant abdominal pain are common findings in cirrhosis and do not warrant urgent intervention. Although ascites and weight gain suggest the need for treatment, they are not as alarming as the neurologic manifestations seen in hepatic encephalopathy.