NCLEX RN Predictor Exam - Nurselytic

Correct Answer: C

Rationale: Creating a latex-safe environment for a patient with latex allergy is crucial to prevent allergic reactions. Using a latex-free pharmacy protocol is essential as it ensures that medications and supplies provided to the patient are free of latex components. Cleaning a wall-mounted blood pressure device may not be sufficient as the device itself may contain latex parts that can trigger an allergic reaction. Donning latex gloves, even outside the room, is not recommended as powder dispersal can cause issues; only non-latex gloves should be used in a latex-safe environment. Placing the patient in a semi-private room does not directly address the need to eliminate latex exposure from medical supplies and equipment, which is better achieved through a latex-free pharmacy protocol.

Correct Answer: A

Rationale: Thorough hand hygiene is the most effective action for controlling the spread of infection as hands are a common source of transmission. Regular and routine hand hygiene helps prevent the movement of potentially infective materials. Wearing gloves and masks is important when providing direct client care to protect both the caregiver and the patient, but it is not as effective as thorough hand hygiene in preventing overall infection spread. Implementing appropriate isolation precautions is necessary for clients with known communicable diseases, but it is not as universally effective in preventing the spread of various infections. Administering broad-spectrum prophylactic antibiotics is not an appropriate measure for controlling the spread of infection as routine use can lead to superinfection and the development of resistant organisms.

Correct Answer: C

Rationale: A patient with blood type AB has AB antigens on their red blood cells. This means they can only receive blood products that are compatible with these antigens.
Choice A is incorrect because an AB patient cannot receive plasma from a type B donor due to the antibodies present in type B plasma.
Choice B is incorrect because an AB patient cannot receive whole blood from a type A donor as it contains incompatible antigens.
Choice C is the correct answer because an AB patient can receive packed RBCs from a type O donor. Type O donors have no A or B antigens, making their blood compatible for transfusion to recipients with any blood type.
Therefore, choices A and B are incorrect, and the correct choice is C.

Correct Answer: B

Rationale: Providing oral hygiene after a meal is an appropriate task to delegate to unlicensed assistive personnel (UAP) as it falls within their scope of practice. UAP can assist with basic personal care activities like oral hygiene. Assessing the patient for jaundice and palpating the abdomen for distention involve making clinical assessments that require a higher level of education and training, typically performed by licensed practical/vocational nurses (LPNs/LVNs) or registered nurses (RNs). Assisting the patient to choose the diet also requires specialized knowledge and would be more appropriate for a nurse to address, considering the complexity of dietary requirements in cirrhosis.

Correct Answer: A

Rationale: The correct answer is, 'Would you describe what you are feeling?' This open-ended question prompts the patient to provide subjective data, offering specific information about their current health status and human responses. This information can help identify actual or potential health issues.

Choices B and C are more likely to yield general, nonspecific information.
Choice D may lead to a brief response or nonverbal indication of pain location. A more effective approach to gather specific information about pain would be to ask, 'Can you describe any pain you are experiencing?'