NCLEX RN Exam Questions - Nurselytic

Correct Answer: D

Rationale: The critical finding that should be reported immediately to the healthcare provider is 'No measurable voiding in 4 hours.' This finding raises concerns about possible hyperkalemia, which can result from continued potassium administration and a decrease in urinary output. Hyperkalemia can lead to serious complications, including cardiac arrhythmias. The management of acute hyperkalemia involves interventions such as administering calcium to protect the heart, shifting potassium into cells, and enhancing potassium elimination from the body. The other choices do not indicate an urgent issue that requires immediate attention. Three episodes of vomiting in 1 hour can be concerning but may not be as immediately critical as the risk of hyperkalemia. Periodic crying and irritability are common in infants and may not indicate a severe complication. Vigorous sucking on a pacifier is a normal behavior in infants and does not signal a medical emergency.

Correct Answer: C

Rationale: The best indicator that propranolol has been effective in a patient with cirrhosis and esophageal varices is when the stools test negative for occult blood. Propranolol is prescribed to decrease the risk of bleeding from esophageal varices. This medication's effectiveness is primarily assessed by the absence of blood in the stools, indicating a reduction in the risk of bleeding from the varices. Monitoring for chest pain, blood pressure control, and a decrease in heart rate are important parameters in other conditions treated with propranolol, such as hypertension, angina, and tachycardia, but in this particular case, the absence of occult blood in the stools is the most relevant indicator of treatment success.

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.

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: A

Rationale: In this scenario, the client's disclosure of having multiple sex partners and uncertainty about the baby's father indicates a potential high risk for HIV.
Therefore, the priority nursing intervention is to counsel the woman to consent to HIV screening. Early detection of HIV is crucial for initiating timely treatment and improving outcomes.

Choices B, C, and D are not the priority in this situation as HIV screening takes precedence over testing for other sexually transmitted diseases, discussing cervical cancer risk, or referring to a family planning clinic.