a patient is diagnosed with both human immunodeficiency virus hiv and active tuberculosis tb disease which information obtained by the nurse is most
Logo

Nursing Elites

NCLEX-RN

NCLEX RN Prioritization Questions

1. A patient is diagnosed with both human immunodeficiency virus (HIV) and active tuberculosis (TB) disease. Which information obtained by the nurse is most important to communicate to the healthcare provider?

Correct answer: C

Rationale: The most critical information to communicate to the healthcare provider in a patient diagnosed with both HIV and active TB disease is that the patient is receiving antiretroviral therapy for HIV infection. This is crucial because drug interactions can occur between antiretrovirals used to treat HIV infection and medications used to treat TB. By informing the healthcare provider about the antiretroviral therapy, potential interactions can be assessed and managed effectively to optimize patient care. The other data provided, such as the Mantoux test result, chest x-ray findings, and presence of blood-tinged mucus, are important clinical information but are expected in a patient with coexisting HIV and TB and do not directly impact potential drug interactions between antiretrovirals and TB medications.

2. The nurse is reviewing the record of a child diagnosed with nephrotic syndrome. The nurse should expect to note which finding documented in the child's record?

Correct answer: B

Rationale: In nephrotic syndrome, a key finding documented in the child's record is weight gain due to massive edema. While urine may appear dark, foamy, and frothy, grossly bloody urine is not expected as only microscopic hematuria is present. Additionally, urine output is decreased, and hypertension is likely to be present. Therefore, the correct answer is weight gain as it aligns with the characteristic presentation of nephrotic syndrome.

3. A patient's chart indicates a history of ketoacidosis. Which of the following would you not expect to see with this patient if this condition were acute?

Correct answer: C

Rationale: In acute ketoacidosis, a patient typically experiences rapid weight loss due to the body burning fat and muscle for energy in the absence of sufficient insulin. Therefore, weight gain would not be expected. Vomiting may occur due to the metabolic disturbances associated with ketoacidosis. Extreme thirst is a common symptom as the body tries to compensate for dehydration. Acetone breath smell is a classic sign of ketoacidosis as acetone is one of the ketones produced during this condition.

4. A patient is being treated in the Neurology Unit for Meningitis. Which of these is a priority assessment for the nurse to make?

Correct answer: D

Rationale: Monitoring for increased lethargy and drowsiness is crucial as these symptoms indicate a decreased level of consciousness, which is the cardinal sign of increased Intracranial Pressure (ICP). Elevated ICP can lead to serious complications and requires immediate intervention. Assessing for nuchal rigidity is important in suspected cases of meningitis but monitoring lethargy and drowsiness takes precedence due to its direct correlation with ICP. Determining past exposure to infectious organisms and checking WBC lab values are important for diagnosing and treating meningitis but do not directly address the immediate concern of increased ICP.

5. A patient comes to the emergency department with abdominal pain. Work-up reveals the presence of a rapidly enlarging abdominal aortic aneurysm. Which of the following actions should the nurse expect?

Correct answer: C

Rationale: A rapidly enlarging abdominal aortic aneurysm is at significant risk of rupture, which can be life-threatening. The standard treatment for a rapidly enlarging abdominal aortic aneurysm is surgical intervention to prevent rupture. Therefore, the appropriate action for the nurse to expect is that the patient will be admitted to the surgical unit, and resection will be scheduled. Observation and medication (Choice A) are not sufficient for a rapidly enlarging aneurysm, and sclerotherapy (Choice B) is not typically used for aortic aneurysms. Discharging the patient home (Choice D) would be inappropriate and dangerous given the risk of rupture.

Similar Questions

The nurse is caring for a post-surgical client at risk for developing deep vein thrombosis. Which intervention is an effective preventive measure?
Which patient is at risk for developing oral candidiasis, a type of stomatitis?
A man is receiving heparin subcutaneously. The patient has dementia and lives at home with a part-time caretaker. The nurse is most concerned about which side effect of heparin?
A patient has a history of photosensitive reactions to medications. Which of the following drugs is associated with photosensitive reactions? Select one that doesn't apply
The nurse is planning care for a 48-year-old woman with acute severe pancreatitis. The highest priority patient outcome is

Access More Features

NCLEX RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access

NCLEX RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access

Other Courses