NCLEX RN Exam Questions

NCLEX RN Exam Questions Related

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Which finding is most important for the nurse to communicate to the health care provider about a patient who received a liver transplant 1 week ago?

  • A. Dry palpebral and oral mucosa
  • B. Crackles at bilateral lung bases
  • C. Temperature 100.8?F (38.2?C)
  • D. No bowel movement for 4 days
Correct Answer: C

Rationale: The correct answer is the patient's temperature of 100.8°F (38.2°C). In a patient who received a liver transplant 1 week ago, a fever is a significant finding that should be promptly communicated to the health care provider. Post-transplant patients are at high risk of infections, and fever can often be the initial indicator of an underlying infectious process. The other findings listed in choices A, B, and D are important and should be addressed, but they do not take precedence over a potential infection post-liver transplant. Dry palpebral and oral mucosa may indicate dehydration, crackles at bilateral lung bases may suggest fluid overload or infection, and no bowel movement for 4 days could indicate a bowel obstruction or ileus. However, in the context of a recent liver transplant, an elevated temperature is the most concerning and requires immediate attention to rule out infection.

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After an unimmunized individual is exposed to hepatitis B through a needle-stick injury, which actions will the nurse plan to take (select one that does not apply)?

  • A. Administer hepatitis B vaccine.
  • B. Test for antibodies to hepatitis B.
  • C. Teach about alpha-interferon therapy.
  • D. Give hepatitis B immune globulin.
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.

The nurse is planning care for a 48-year-old woman with acute severe pancreatitis. The highest priority patient outcome is

  • A. maintaining normal respiratory function.
  • B. expressing satisfaction with pain control.
  • C. developing no ongoing pancreatic disease.
  • D. having adequate fluid and electrolyte balance.
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.

The patient with chronic pancreatitis will be taught to take the prescribed pancrelipase (Viokase)

  • A. at bedtime.
  • B. in the morning.
  • C. with each meal.
  • D. for abdominal pain.
Correct Answer: C

Rationale: The correct answer is to take pancrelipase (Viokase) with each meal. Pancrelipase is a pancreatic enzyme replacement medication that helps with the digestion of nutrients. Patients with chronic pancreatitis often have difficulty digesting food properly due to insufficient pancreatic enzyme production. Taking pancrelipase with each meal assists in the breakdown of fats, proteins, and carbohydrates consumed during the meal. Option A ('at bedtime') is incorrect because enzymes should be taken with meals to aid in digestion. Option B ('in the morning') is not ideal as it does not ensure optimal enzyme activity during meals. Option D ('for abdominal pain') is incorrect as pancrelipase is not meant to be taken solely for pain relief but rather to aid in digestion.

Which assessment finding would the nurse need to report most quickly to the health care provider regarding a patient with acute pancreatitis?

  • A. Nausea and vomiting
  • B. Hypotonic bowel sounds
  • C. Abdominal tenderness and guarding
  • D. Muscle twitching and finger numbness
Correct Answer: D

Rationale: The correct answer is muscle twitching and finger numbness. These symptoms indicate hypocalcemia, which can lead to tetany if not promptly addressed with calcium gluconate administration. Nausea and vomiting, hypotonic bowel sounds, and abdominal tenderness and guarding are important findings in acute pancreatitis but do not require the same urgent intervention as hypocalcemia to prevent potential severe complications.

A 49-year-old female patient with cirrhosis and esophageal varices has a new prescription for propranolol (Inderal). Which finding is the best indicator that the medication has been effective?

  • A. The patient reports no chest pain.
  • B. Blood pressure is 140/90 mm Hg
  • C. Stools test negative for occult blood.
  • D. The apical pulse rate is 68 beats/minute.
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.

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