NCLEX-RN Practice Exam 5
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 tongue is smooth and beefy red in the client with vitamin B12 deficiency, so examining the tongue should be included in the physical assessment. Bleeding, Options A, B, and C: Bleeding, splenomegaly, and blood pressure changes do not occur.
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?
During induction chemotherapy, the leukemia patient is severely immunocompromised and at risk of serious infection. Fresh flowers, fruit, and plants can carry microbes and should be avoided. Options A, B, and D: Books, pictures, and other personal items can be cleaned with antimicrobials before being brought into the room to minimize the risk of contamination.
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?
A definitive diagnosis of Hodgkin's disease is made if Reed-Sternberg cells are found on pathologic examination of the excised lymph node. Option B: Lymphoblasts are immature cells found in the bone marrow of patients with acute lymphoblastic leukemia. Option C: Gaucher's cells are large storage cells found in patients with Gaucher's disease. Option D: Rieder's cells are myeloblasts found in patients with acute myelogenous leukemia.
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.
The most prominent clinical manifestation of sickle cell crisis is pain. However, the pulse oximetry indicates that oxygen levels are low; thus, oxygenation takes precedence over pain relief. Option A: Warm environment reduces pain and minimizes sickling, it would not be a priority. Option B: Although hydration is important, it would not require a bolus. Option D: Demerol is acidifying to the blood and increases sickling.
A client with hemophilia has a nosebleed. Which nursing action is most appropriate to control the bleeding?
The client should be positioned upright and leaning forward, to prevent aspiration of blood. Options A, B, and D: Direct pressure to the nose stops the bleeding, and ice packs should be applied directly to the nose as well. If a pack is necessary, the nares are loosely packed.
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?
Exercise is important for all hospitalized patients to prevent deep vein thrombosis. Muscular contraction promotes venous return and prevents hemostasis in the lower extremities. Options A, B, and D: This exercise is not sufficiently vigorous to increase physical fitness, nor is it intended to prevent bedsores or constipation.
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?
The oral mucosa and hard palate (roof of the mouth) are the best indicators of jaundice in dark-skinned persons. Option A: The conjunctiva can have normal deposits of fat, which give a yellowish hue. Option B: The soles of the feet can be yellow if they are calloused. Option D: The shins would be an area of darker pigment.
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?
Petechiae are not usually visualized on dark skin. The soles of the feet and palms of the hand provide a lighter surface for assessing the client for petechiae. Options A, B, and C: The skin in the abdomen, thorax, and earlobes might be too dark to make an assessment.
A hospitalized patient is receiving packed red blood cells (PRBCs) for treatment of severe anemia. Which of the following is the most accurate statement?
Transfusion reaction is most likely during the first 15 minutes of infusion, and a nurse should be present during this period. Option B: PRBCs should be infused through a 19g or larger IV catheter to avoid slow flow, which can cause clotting. Option C: PRBCs must be flushed with 0.45% normal saline solution. Other intravenous solutions will hemolyze the cells.