NCLEX Practice Exam 5

Question 1

The nurse is conducting an admission assessment of a client with vitamin B12 deficiency. Which of the following would the nurse include in the physical assessment?

Accepted Answer

Examine the tongue

Answer

Palpate the spleen

Answer

Take the blood pressure

Answer

Examine the feet for petechiae

Question 2

The Hodgkin’s disease patient described in the question above undergoes a lymph node biopsy for definitive diagnosis. If the diagnosis of Hodgkin’s disease were correct, which of the following cells would the pathologist expect to find?

Accepted Answer

Reed-Sternberg cells.

Answer

Lymphoblastic cells.

Answer

Gaucher’s cells.

Answer

Rieder’s cells

Question 3

A newly admitted client has sickle cell crisis. The nurse is planning care based on assessment of the client. The client is complaining of severe pain in his feet and hands. The pulse oximetry is 92. Which of the following interventions would be implemented first? Assume that there are orders for each intervention.

Accepted Answer

Start O2

Answer

Adjust the room temperature

Answer

Give a bolus of IV fluids

Answer

Administer meperidine (Demerol) 75 mg IV push

Question 4

An African American female comes to the outpatient clinic. The physician suspects vitamin B12 deficiency anemia. Because jaundice is often a clinical manifestation of this type of anemia, what body part would be the best indicator?

Accepted Answer

Roof of the mouth

Answer

Conjunctiva of the eye

Answer

Soles of the feet

Answer

Shins

Question 5

An African American client is admitted with acute leukemia. The nurse is assessing for signs and symptoms of bleeding. Where is the best site for examining for the presence of petechiae?

Accepted Answer

The soles of the feet

Answer

The abdomen

Answer

The thorax

Answer

The earlobes

Question 6

Following myocardial infarction, a hospitalized patient is encouraged to practice frequent leg exercises and ambulate in the hallway as directed by his physician. Which of the following choices reflects the purpose of exercise for this patient?

Accepted Answer

Prevents DVT (deep vein thrombosis).

Answer

Increases fitness and prevents future heart attacks.

Answer

Prevents bedsores.

Answer

Prevent constipations.

Question 7

A hospitalized patient is receiving packed red blood cells (PRBCs) for treatment of severe anemia. Which of the following is the most accurate statement?

Accepted Answer

A nurse should remain in the room during the first 15 minutes of infusion.

Answer

Transfusion reaction is most likely immediately after the infusion is completed.

Answer

PRBCs are best infused slowly through a 20g. IV catheter.

Answer

PRBCs should be flushed with a 5% dextrose solution.

Question 8

A client with hemophilia has a nosebleed. Which nursing action is most appropriate to control the bleeding?

Accepted Answer

Pinch the soft lower part of the nose for a minimum of 5 minutes

Answer

Place the client in a sitting position with the head hyperextended

Answer

Pack the nares tightly with gauze to apply pressure to the source of bleeding

Answer

Apply ice packs to the forehead and back of the neck

Question 9

A patient is undergoing the induction stage of treatment for leukemia. The nurse teaches family members about infectious precautions. Which of the following statements by family members indicates that the family needs more education?

Accepted Answer

We will bring in fresh flowers to brighten the room.

Answer

We will bring in books and magazines for entertainment.

Answer

We will bring in personal care items for comfort.

Answer

We will bring in family pictures and get well cards.

Question 10

Dave, a 6-year-old boy, was rushed to the hospital following her mother’s complaint that her son has been vomiting, nauseated and has overall weakness. After series of tests, the nurse notes the laboratory results: potassium: 2.9 mEq. Which primary acid-base imbalance is this boy at risk for if medical intervention is not carried out?

Accepted Answer

Metabolic Alkalosis

Answer

Respiratory Acidosis

Answer

Respiratory Alkalosis

Answer

Metabolic Acidosis

The nurse is conducting an admission assessment of a client with vitamin B12 deficiency.Which of the following would the nurse include in the physical assessment?

The nurse is conducting an admission assessment of a client with vitamin B12 deficiency.
Which of the following would the nurse include in the physical assessment?