which assessment information will be most important for the nurse to report to the health care provider about a patient with acute cholecystitis
Logo

Nursing Elites

NCLEX-RN

NCLEX RN Exam Questions

1. Which assessment information will be most important for the nurse to report to the healthcare provider about a patient with acute cholecystitis?

Correct answer: B

Rationale: The correct answer is that the patient's stools are tan colored. Tan or grey stools indicate biliary obstruction, which requires rapid intervention to resolve in a patient with acute cholecystitis. This change in stool color is a critical sign that the healthcare provider needs to be informed about promptly. The other choices are less concerning and may be common symptoms in patients with acute cholecystitis, but tan-colored stools specifically indicate a potential serious complication that warrants immediate attention.

2. A pregnant woman who is 36 weeks' pregnant and has hepatitis B is being informed by a nurse. Which of the following statements from the client indicates understanding of this condition?

Correct answer: B

Rationale: The correct answer is 'My baby will need two shots soon after birth.' A baby born to a mother with hepatitis B should receive two injections soon after birth to reduce the risk of contracting the disease. Within the first 12 hours post-birth, the baby should receive the first hepatitis B vaccine and hepatitis B immune globulin (HBIG) for additional protection. Option A is incorrect because the need for a cesarean section is not directly related to the mother's hepatitis B status. Option C is incorrect as breastfeeding can be safe if managed properly. Option D is incorrect as the baby's father should also be tested for hepatitis B to prevent transmission to the newborn.

3. In educating clients on ways to manage pain, which topic can be appropriately delegated to an LPN/LVN who will continue under supervision?

Correct answer: C

Rationale: The correct answer is 'Alternating Rest/Activity.' This topic falls within the nursing scope of practice and is typically covered in the training and education of all nurses, including LPN/LVNs. Educating clients on alternating rest and activity is safe, straightforward, and a standard non-pharmacological pain management strategy. Acupuncture (Choice A) and Guided Imagery (Choice B) involve specific skills and techniques that are typically outside the scope of practice for LPN/LVNs. Over-the-counter medications (Choice D) may require additional assessment, monitoring, and considerations that are beyond the usual delegation for LPN/LVNs.

4. The nurse administers prescribed therapies for a patient with cor pulmonale and right-sided heart failure. Which assessment would best evaluate the effectiveness of the therapies?

Correct answer: A

Rationale: To evaluate the effectiveness of therapies for cor pulmonale and right-sided heart failure, observing for distended neck veins would be the most appropriate assessment. Cor pulmonale is characterized by right ventricular failure due to pulmonary hypertension, leading to clinical manifestations such as peripheral edema, jugular venous distention, and right upper-quadrant abdominal tenderness. These signs indicate increased central venous pressure and right heart strain, which can be assessed by observing for distended neck veins. Auscultating for crackles in the lungs is more indicative of left-sided heart failure rather than right-sided heart failure. Heaves or thrills over the heart are not typically associated with cor pulmonale. Reviewing hemoglobin and hematocrit values may show elevations due to chronic hypoxemia and polycythemia in cor pulmonale, but these values alone do not directly evaluate the immediate effectiveness of the prescribed therapies on the patient's condition.

5. A 34-year-old patient with chronic hepatitis C infection has several medications prescribed. Which medication requires further discussion with the healthcare provider before administration?

Correct answer: B

Rationale: The correct answer is B: Pegylated ?-interferon (PEG-Intron, Pegasys) SQ weekly. Pegylated ?-interferon is typically administered once weekly, not daily. Therefore, this medication requires further discussion with the healthcare provider before administration to ensure the correct dosing frequency. Ribavirin, choice A, is appropriate for chronic hepatitis C treatment. Choices C and D, Diphenhydramine and Dimenhydrinate, are commonly used for symptomatic relief in patients with hepatitis C and do not require further discussion with the healthcare provider in this context.

Similar Questions

While auscultating a patient's lungs, the nurse hears low-pitched, bubbling sounds during inhalation in the lower third of both lungs. How should the nurse document this finding?
The nurse prepares a patient with a left-sided pleural effusion for a thoracentesis. How should the nurse position the patient?
Mr. L was working in his garage at home and had an accident with a power saw. He is brought into the emergency department by a neighbor with a traumatic hand amputation. What is the first action of the nurse?
The nurse is discussing negativism with the parents of a 30-month-old child. How should the nurse advise the parents to best respond to this behavior?
After assessing Mr. B, what is the initial action of the nurse?

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