NCLEX RN Exam Questions - Nurselytic

Correct Answer: A

Rationale: The most critical assessment data for the nurse to communicate to the healthcare provider in a patient with acute liver failure are asterixis and lethargy. These findings are indicative of grade 2 hepatic encephalopathy, which signals a rapid deterioration in the patient's condition, necessitating early transfer to a transplant center. Jaundiced sclera and skin, elevated total bilirubin level, and a liver 3 cm below the costal margin are all typical findings in hepatic failure but do not indicate an immediate need for a change in the therapeutic plan.
Therefore, while these findings are relevant and should be reported, they are not as urgent as asterixis and lethargy in a patient with acute liver failure.

Correct Answer: C

Rationale: In the case of exposure to hepatitis B, the nurse should plan to administer hepatitis B vaccine to provide active immunity. Testing for antibodies to hepatitis B is essential to determine the individual's immune status. Giving hepatitis B immune globulin is necessary for passive immunity in cases of exposure. However, teaching about alpha-interferon therapy is not part of the standard management for hepatitis B exposure. Interferon therapy and oral antivirals are typically used in the treatment of chronic hepatitis B infections, not for prophylaxis after exposure.

Correct Answer: A

Rationale: The correct answer is 'Fever and rash.' Rocky Mountain Spotted Fever (RMSP) is caused by the R. rickettsii pathogen, which damages blood vessels. Patients with RMSP typically present with fever, edema, and a rash that initially appears on the hands and feet before spreading across the body. The disease manifests following a tick bite.
Choice A is correct as fever and rash are key indicators of RMSP. Circumoral cyanosis (choice
B) is not typically associated with RMSP; it refers to a bluish discoloration around the mouth and is more indicative of oxygen deprivation. Elevated glucose levels (choice
C) are not specific signs of RMSP.
Therefore, choice D, 'All of the above,' is incorrect since only choice A, 'Fever and rash,' is associated with Rocky Mountain Spotted Fever.

Correct Answer: C

Rationale: The patient with a healing leg wound poses the least infection risk to an immunosuppressed patient who had a liver transplant. Chronic pancreatitis can lead to complications such as infections that can pose a risk to immunosuppressed individuals. Patients infected with respiratory viruses or urinary tract infections are actively infectious, which can put immunosuppressed patients at a higher risk of acquiring infections.
Therefore, the patient with a healing leg wound is the least likely to pose an immediate infection risk.

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.