the nurse is planning care for a 48 year old woman with acute severe pancreatitis the highest priority patient outcome is
Logo

Nursing Elites

NCLEX-RN

NCLEX RN Exam Questions

1. 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.

2. Using the illustrated technique, the healthcare provider is assessing for which finding in a patient with chronic obstructive pulmonary disease (COPD)?

Correct answer: D

Rationale: The technique for palpation for chest expansion is shown in the illustrated technique. Reduced chest expansion would be noted on palpation of a patient's chest with COPD. Hyperresonance would be assessed through percussion, not palpation. Accessory muscle use and tripod positioning would be assessed by inspection, not palpation.

3. The patient with idiopathic pulmonary arterial hypertension (IPAH) is receiving epoprostenol (Flolan). Which assessment information requires the most immediate action by the nurse?

Correct answer: C

Rationale: The most immediate action required by the nurse is to address the disconnected central IV line delivering epoprostenol (Flolan). Epoprostenol has a short half-life of 6 minutes, necessitating immediate reconnection to prevent rapid clinical deterioration. While oxygen saturation, blood pressure, and INR are important parameters requiring monitoring and intervention, the priority lies in ensuring the continuous delivery of the critical medication to stabilize the patient's condition.

4. While working with an obese adolescent, it is important for the nurse to recognize that obesity in adolescents is most often associated with what other behavior?

Correct answer: B

Rationale: When addressing obesity in adolescents, it is crucial to consider that poor body image is a common behavior associated with obesity. As adolescents gain weight, they may experience a decrease in self-esteem and a negative perception of their body. This can contribute to a cycle of unhealthy behaviors and impact their overall well-being. The other choices are less commonly associated with obesity in adolescents. Sexual promiscuity may be influenced by various factors unrelated to obesity, dropping out of school is more often linked to academic challenges or social issues, and drug experimentation can stem from a range of influences but is not directly correlated with obesity.

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.

Similar Questions

A diabetic patient's arterial blood gas (ABG) results are pH 7.28; PaCO2 34 mm Hg; PaO2 85 mm Hg; HCO3 18 mEq/L. The nurse would expect which finding?
A patient is suspected to have sustained a spinal cord injury. What best describes the overarching principles used to guide the care for this type of condition?
The mother of a child with hepatitis A tells the home care nurse that she is concerned because the child's jaundice seems worse. What is the nurse's best response?
A patient has just been admitted with probable bacterial pneumonia and sepsis. Which order should the nurse implement first?
The nurse notes that a patient has incisional pain, a poor cough effort, and scattered rhonchi after a thoracotomy. Which action should the nurse take first?

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