NCLEX-RN
NCLEX RN Prioritization Questions
1. A client was recently diagnosed with diverticulosis. What types of foods should the nurse recommend for this client?
- A. Whole grain cereal
- B. Eggs
- C. Cottage cheese
- D. Fish
Correct answer: A
Rationale: Diverticulosis is a condition characterized by small protrusions in the intestinal tract. To manage diverticulosis, a high-fiber diet is recommended. Foods rich in fiber help prevent constipation and reduce the risk of inflammation in the intestines. Whole grain cereals are an excellent source of fiber and can aid in maintaining bowel regularity. Eggs, cottage cheese, and fish are not high-fiber foods and may not provide the necessary dietary support for a client with diverticulosis. While protein-rich foods like eggs and fish are beneficial for overall health, they are not the primary recommendation for managing diverticulosis.
2. A patient is scheduled for a magnetic resonance imaging (MRI) scan for suspected lung cancer. Which of the following is a contraindication to the study for this patient?
- A. The patient is allergic to shellfish.
- B. The patient has a pacemaker.
- C. The patient suffers from claustrophobia.
- D. The patient takes antipsychotic medication.
Correct answer: B
Rationale: The correct answer is that the patient has a pacemaker. A pacemaker is a contraindication to MRI scanning due to the interference with the magnetic fields of the MRI scanner. This interference can potentially deactivate the pacemaker, putting the patient at risk. Patients with cardiac implantable electronic devices (CIED) are at risk for inappropriate device therapy, device heating/movement, and arrhythmia during MRI. This necessitates special precautions such as scheduling in a CIED blocked slot or having electrophysiology nurse or technician support. It is important to ensure that the patient's pacemaker is MRI conditional before proceeding with the scan. The other choices, such as being allergic to shellfish, suffering from claustrophobia, or taking antipsychotic medication, are not direct contraindications to undergoing an MRI scan for suspected lung cancer.
3. The nurse is collecting data on a child recently diagnosed with glomerulonephritis. Which question to the mother should elicit data associated with the cause of this disease?
- A. ''Has your child had any nausea or diarrhea?''
- B. ''Have you noticed any rashes on your child?''
- C. ''Did your child recently complain of a sore throat?''
- D. ''Did your child sustain any injuries to the kidney area?''
Correct answer: C
Rationale: The correct answer is 'Did your child recently complain of a sore throat?' Group A beta-hemolytic streptococcal infection is a known cause of glomerulonephritis. In this condition, the child typically becomes ill with streptococcal infection of the upper respiratory tract, and then after 1 to 2 weeks, symptoms of acute poststreptococcal glomerulonephritis can develop. This question aims to gather crucial information related to a potential trigger for glomerulonephritis. Choices A, B, and D are incorrect because they do not pertain to a common cause or associated symptom of glomerulonephritis.
4. A nurse is caring for a patient admitted to the emergency room for an ischemic stroke with marked functional deficits. The physician is considering the use of fibrinolytic therapy with TPA (tissue plasminogen activator). Which history-gathering question would not be important for the nurse to ask?
- A. What time did you first notice symptoms consistently appearing?
- B. Have you been taking any blood thinners such as heparin, lovenox, or warfarin?
- C. Have you had another stroke or head trauma in the previous 3 months?
- D. Have you had any blood transfusions within the previous year?
Correct answer: D
Rationale: The correct answer is 'Have you had any blood transfusions within the previous year?' This question is not relevant in the context of considering fibrinolytic therapy with TPA for an ischemic stroke. Blood transfusions within the previous year do not directly impact the decision to use TPA in the treatment of an acute ischemic stroke. The focus should be on factors such as the time of symptom onset, current medications like blood thinners, and recent history of strokes or head trauma, as these are more directly related to the decision-making process for administering TPA in this emergency situation.
5. A patient is admitted to the emergency department complaining of sudden onset shortness of breath and is diagnosed with a possible pulmonary embolus. How should the nurse prepare the patient for diagnostic testing to confirm the diagnosis?
- A. Start an IV so contrast media may be given
- B. Ensure that the patient has been NPO for at least 6 hours.
- C. Inform radiology that a radioactive glucose preparation is needed
- D. Instruct the patient to undress to the waist and remove any metal objects
Correct answer: A
Rationale: For diagnosing pulmonary emboli, spiral computed tomography (CT) scans are commonly used, and contrast media may be given intravenously (IV) during the scan to enhance visualization of blood vessels. Chest x-rays are not typically diagnostic for pulmonary embolism. When preparing for a chest x-ray, the patient needs to undress and remove any metal objects. Bronchoscopy is used for examining the bronchial tree, not for assessing vascular changes, and the patient should be NPO 6 to 12 hours before the procedure. Positron emission tomography (PET) scans are primarily used to detect malignancies, and a radioactive glucose preparation is utilized for this purpose.
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