NCLEX-RN Practice Exam 5

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The nurse is teaching the client with polycythemia vera about prevention of complications of the disease. Which of the following statements by the client indicates a need for further teaching?

Correct! Wrong!

The client with polycythemia vera is at risk for thrombus formation. Hydrating the client with at least 3L of fluid per day is important in preventing clot formation, so the statement to drink less than 500mL is incorrect. Options B, C, and D: Support hose promotes venous return, the electric razor prevents bleeding due to injury, and a diet low in iron is essential to preventing further red cell formation.

A client has had a unilateral adrenalectomy to remove a tumor. To prevent complications, the most important measurement in the immediate postoperative period for the nurse to take is:

Correct! Wrong!

Blood pressure is the best indicator of cardiovascular collapse in the client who has had an adrenal gland removed. The remaining gland might have been suppressed due to the tumor activity. Temperature would be an indicator of infection, Options B, C, and D: Temperature would be an indicator of infection, decreased output would be a clinical manifestation but would take longer to occur than blood pressure changes, and specific gravity changes occur with other disorders.

A nurse is administering IV furosemide to a patient admitted with congestive heart failure. After the infusion, which of the following symptoms is NOT expected?

Correct! Wrong!

Furosemide, a loop diuretic, does not alter pain. Option A: Furosemide acts on the kidneys to increase urinary output. Option B: Fluid may move from the periphery, decreasing edema. Option D: Fluid load is reduced, lowering blood pressure.

A clinic patient has recently been prescribed nitroglycerin for treatment of angina. He calls the nurse complaining of frequent headaches. Which of the following responses to the patient is correct?

Correct! Wrong!

Nitroglycerin is a potent vasodilator and often produces unwanted effects such as headache, dizziness, and hypotension. Patients should be counseled, and the dose titrated, to minimize these effects. In spite of the side effects, nitroglycerin is effective at reducing myocardial oxygen consumption and increasing blood flow. Option A: The patient should not stop the medication. Option B: Nitroglycerine does not cause bleeding in the brain.

A patient arrives in the emergency department with symptoms of myocardial infarction, progressing to cardiogenic shock. Which of the following symptoms should the nurse expect the patient to exhibit with cardiogenic shock?

Correct! Wrong!

Cardiogenic shock severely impairs the pumping function of the heart muscle, causing diminished blood flow to the organs of the body. This results in diminished brain function and confusion, as well as hypotension, tachycardia, and weak pulse. Cardiogenic shock is a serious complication of myocardial infarction with a high mortality rate.

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.

Correct! Wrong!

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 a pituitary tumor has had a transsphenoidal hypophysectomy. Which of the following interventions would be appropriate for this client?

Correct! Wrong!

Elevating the head of the bed 30° avoids pressure on the sella turcica and alleviates headaches. Options A, B, and D: Trendelenburg, Valsalva maneuver, and coughing all increase the intracranial pressure.

A patient is admitted to the hospital with suspected polycythemia vera. Which of the following symptoms is consistent with the diagnosis? Select all that applies.

Please select 3 correct answers

Correct! Wrong!

Polycythemia vera is a condition in which the bone marrow produces too many red blood cells. This causes an increase in hematocrit and viscosity of the blood. Patients can experience headaches, dizziness, and visual disturbances. Cardiovascular effects include increased blood pressure and delayed clotting time. Option A: Weight loss is not a manifestation of polycythemia vera.

The home health nurse is visiting a client with autoimmune thrombocytopenic purpura (ATP). The client’s platelet count currently is 80, It will be most important to teach the client and family about:

Correct! Wrong!

The normal platelet count is 120,000–400, Bleeding occurs in clients with low platelets. The priority is to prevent and minimize bleeding. Options B and D are of lesser priority and are incorrect in this instance. Option C is important, but platelets do not carry oxygen.

A 32-year-old mother of three is brought to the clinic. Her pulse is 52, there is a weight gain of 30 pounds in 4 months, and the client is wearing two sweaters. The client is diagnosed with hypothyroidism. Which of the following nursing diagnoses is of highest priority?

Correct! Wrong!

The decrease in pulse can affect the cardiac output and lead to shock, which would take precedence over the other choices; therefore, answers A, B, and C are incorrect.

A 21-year-old male with Hodgkin’s lymphoma is a senior at the local university. He is engaged to be married and is to begin a new job upon graduation. Which of the following diagnoses would be a priority for this client?

Correct! Wrong!

Radiation therapy often causes sterility in male clients and would be of primary importance to this client. The psychosocial needs of the client are important to address in light of the age and life choices. Hodgkin’s disease, however, has a good prognosis when diagnosed early. Answers B, C, and D are incorrect because they are of lesser priority.

Which of the following would be the priority nursing diagnosis for the adult client with acute leukemia?

Correct! Wrong!

The client with acute leukemia has bleeding tendencies due to decreased platelet counts, and any injury would exacerbate the problem. The client would require close monitoring for hemorrhage, which is of higher priority than the diagnoses in answers A, C, and D, which are incorrect.

A nurse in the emergency department assesses a patient who has been taking long-term corticosteroids to treat renal disease. Which of the following is a typical side effect of corticosteroid treatment? Note: More than one answer may be correct.

Please select 3 correct answers

Correct! Wrong!

Side effects of corticosteroids include weight gain, fluid retention with hypertension, Cushingoid features, a low serum albumin, and suppressed inflammatory response. Patients are encouraged to eat a diet high in protein, vitamins, and minerals and low in sodium. Option C: Corticosteroids cause hypernatremia and not hyponatremia.

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

Correct! Wrong!

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.

Tissue plasminogen activator (t-PA) is considered for treatment of a patient who arrives in the emergency department following onset of symptoms of myocardial infarction. Which of the following is a contraindication for treatment with t-PA?

Correct! Wrong!

A history of cerebral hemorrhage is a contraindication to tPA because it may increase the risk of bleeding. TPA acts by dissolving the clot blocking the coronary artery and works best when administered within 6 hours of onset of symptoms. Option C: Prior MI is not a contraindication to tPA. Option D: Patients receiving tPA should be observed for changes in blood pressure, as tPA may cause hypotension.

A nurse is caring for patients in the oncology unit. Which of the following is the most important nursing action when caring for a neutropenic patient?

Correct! Wrong!

The neutropenic patient is at risk of infection. Changing gloves immediately after use protects patients from contamination with organisms picked up on hospital surfaces. This contamination can have serious consequences for an immunocompromised patient. Option A: Changing the respiratory mask is desirable, but not nearly as urgent as changing gloves. Options C and D: Minimizing contact and conversation are not necessary and may cause nursing staff to miss changes in the patient's symptoms or condition.

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?

Correct! Wrong!

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.

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?

Correct! Wrong!

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.

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?

Correct! Wrong!

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.

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

Correct! Wrong!

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.

The nurse is instructing a client with iron-deficiency anemia. Which of the following meal plans would the nurse expect the client to select?

Correct! Wrong!

Egg yolks, wheat bread, carrots, raisins, and green, leafy vegetables are all high in iron, which is an important mineral for this client. Options A, B, and D: Roast beef, cabbage, and pork chops are also high in iron, but the side dishes accompanying these choices are not.

A patient with a history of congestive heart failure arrives at the clinic complaining of dyspnea. Which of the following actions is the first the nurse should perform?

Correct! Wrong!

A patient with congestive heart failure and dyspnea may have pulmonary edema, which can cause severe hypertension. Therefore, taking the patient's blood pressure should be the first action. Option A: Lying flat on the exam table would likely worsen the dyspnea, and the patient may not tolerate it. Option B: Blood draws for chemistry and ABG will be required, but not prior to the blood pressure assessment.

A nurse is caring for a patient with a platelet count of 20,000/microliter. Which of the following is an important intervention?

Correct! Wrong!

Platelet counts under 30,000/microliter may cause spontaneous petechiae and bruising, particularly in the extremities. When the count falls below 15,000, spontaneous bleeding into the brain and internal organs may occur. Headaches may be a sign and should be watched for. Options B and D: Thrombocytopenia does not compromise immunity, and there is no reason to limit visitors as long as any physical trauma is prevented. Option C: Aspirin disables platelets and should never be used in the presence of thrombocytopenia.

A 43-year-old African American male is admitted with sickle cell anemia. The nurse plans to assess circulation in the lower extremities every 2 hours. Which of the following outcome criteria would the nurse use?

Correct! Wrong!

It is important to assess the extremities for blood vessel occlusion in the client with sickle cell anemia because a change in capillary refill would indicate a change in circulation. Options A, B, and C: Body temperature, motion, and sensation would not give information regarding peripheral circulation.

A nurse is caring for a patient with acute lymphoblastic leukemia (ALL). Which of the following is the most likely age range of the patient?

Correct! Wrong!

The peak incidence of ALL is at 4 years (range 3-10). It is uncommon after the mid-teen years. The peak incidence of chronic myelogenous leukemia (CML) is 45-55 years. The peak incidence of acute myelogenous leukemia (AML) occurs at 60 years. Two-thirds of cases of chronic lymphocytic leukemia (CLL) occur after 60 years.

The client with a history of diabetes insipidus is admitted with polyuria, polydipsia, and mental confusion. The priority intervention for this client is:

Correct! Wrong!

A large amount of fluid loss can cause fluid and electrolyte imbalance that should be corrected. The loss of electrolytes would be reflected in the vital signs. Option A: Measuring the urinary output is important, but the stem already says that the client has polyuria. Option C: Encouraging fluid intake will not correct the problem. Option D: Weighing the client is not necessary at this time.

The nurse is conducting a physical assessment on a client with anemia. Which of the following clinical manifestations would be most indicative of the anemia?

Correct! Wrong!

When there are fewer red blood cells, there is less hemoglobin and less oxygen. Therefore, the client is often short of breath. Options A, C, and D: The client with anemia is often pale in color, has weight loss, and may be hypotensive.

Clients with sickle cell anemia are taught to avoid activities that cause hypoxia and hypoxemia. Which of the following activities would the nurse recommend?

Correct! Wrong!

Taking a trip to the museum is the only answer that does not pose a threat. Options A, B, and C: A family vacation in the Rocky Mountains at high altitudes, cold temperatures, and airplane travel can cause sickling episodes and should be avoided.

Which of the following foods would the nurse encourage the client in sickle cell crisis to eat?

Correct! Wrong!

Hydration is important in the client with sickle cell disease to prevent thrombus formation. Popsicles, gelatin, juice, and pudding have high fluid content. Options A, B, and D do not aid in hydration and are, therefore, incorrect.

A client has autoimmune thrombocytopenic purpura. To determine the client’s response to treatment, the nurse would monitor:

Correct! Wrong!

Clients with autoimmune thrombocytopenic purpura (ATP) have low platelet counts, making answer A the correct answer. Options B, C, and D: White cell counts, potassium levels, and PTT are not affected in ATP.

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?

Correct! Wrong!

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 admitted to the oncology unit for diagnosis of suspected Hodgkin’s disease. Which of the following symptoms is typical of Hodgkin’s disease?

Correct! Wrong!

Symptoms of Hodgkin's disease include night sweats, fatigue, weakness, and tachycardia. Option A: The disease is characterized by painless, enlarged cervical lymph nodes. Option C: Nausea and vomiting are not typically symptoms of Hodgkin's disease. Option D: Weight loss occurs early in the disease.

A patient is about to undergo bone marrow aspiration and biopsy and expresses fear and anxiety about the procedure. Which of the following is the most effective nursing response?

Correct! Wrong!

Slow, deep breathing is the most effective method of reducing anxiety and stress. It reduces the level of carbon dioxide in the brain to increase calm and relaxation. Option A: Warning the patient to remain still will likely increase her anxiety. Option B: Encouraging family members to stay with the patient may make her worry about their anxiety as well as her own. Option D: Delaying the procedure is unlikely to allay her fears.

A patient who has received chemotherapy for cancer treatment is given an injection of Epoetin. Which of the following should reflect the findings in a complete blood count (CBC) drawn several days later?

Correct! Wrong!

Epoetin is a form of erythropoietin, which stimulates the production of red blood cells, causing an increase in hematocrit. Epoetin is given to patients who are anemic, often as a result of chemotherapy treatment. Options A, C, and D: Epoetin has no effect on neutrophils, platelets, or serum iron.

A 25-year-old male is admitted in sickle cell crisis. Which of the following interventions would be of highest priority for this client?

Correct! Wrong!

It is important to keep the client in sickle cell crisis hydrated to prevent further sickling of the blood. Option A: Taking hourly blood pressures with mechanical cuff is incorrect because a mechanical cuff places too much pressure on the arm. Option C: Position in high Fowler’s with knee gatch raised is inappropriate because it impedes circulation. Option D: Administering Tylenol is too mild an analgesic for the client in crisis.

A client with acute leukemia is admitted to the oncology unit. Which of the following would be most important for the nurse to inquire?

Correct! Wrong!

The client with leukemia is at risk for infection and has often had recurrent respiratory infections during the previous 6 months. Options A, C, and D: Insomnolence, weight loss, and a decrease in alertness also occur in leukemia, but bleeding tendencies and infections are the primary clinical manifestations.

There are a number of risk factors associated with coronary artery disease. Which of the following is a modifiable risk factor?

Correct! Wrong!

Furosemide, a loop diuretic, does not alter pain. Option A: Furosemide acts on the kidneys to increase urinary output. Option B: Fluid may move from the periphery, decreasing edema. Option D: Fluid load is reduced, lowering blood pressure.

A clinic patient has a hemoglobin concentration of 10.8 g/dL and reports sticking to a strict vegetarian diet. Which of the follow nutritional advice is appropriate?

Correct! Wrong!

Normal hemoglobin values range from 11.5-15.0. This vegetarian patient is mildly anemic. When food is prepared in iron cookware its iron content is increased. Option A: In addition, dark green leafy vegetables, such as spinach and kale, and legumes are high in iron. Option B: Mild anemia does not require that animal sources of iron be added to the diet. Many non-animal sources are available. Option D: Coffee and tea increase gastrointestinal activity and inhibit absorption of iron.

A 30-year-old male from Haiti is brought to the emergency department in sickle cell crisis. What is the best position for this client?

Correct! Wrong!

Placing the client in semi-Fowler’s position provides the best oxygenation for this client. Options A, B, and C: Flexion of the hips and knees, which includes the knee-chest position, impedes circulation and is not correct positioning for this client.

A client with Addison’s disease has been admitted with a history of nausea and vomiting for the past 3 days. The client is receiving IV glucocorticoids (Solu-Medrol). Which of the following interventions would the nurse implement?

Correct! Wrong!

IV glucocorticoids raise the glucose levels and often require coverage with insulin. Options B, C, and D: Intake/output measurements is not necessary at this time, sodium and potassium levels would be monitored when the client is receiving mineralocorticoids, and daily weights is unnecessary.

A 33-year-old male is being evaluated for possible acute leukemia. Which of the following would the nurse inquire about as a part of the assessment?

Correct! Wrong!

Radiation treatment for other types of cancer can result in leukemia. Some hobbies and occupations involving chemicals are linked to leukemia. Option D: he incidence of leukemia is higher in twins than in siblings.

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?

Correct! Wrong!

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.

A client had a total thyroidectomy yesterday. The client is complaining of tingling around the mouth and in the fingers and toes. What would the nurses’ next action be?

Correct! Wrong!

The parathyroid glands are responsible for calcium production and can be damaged during a thyroidectomy. The tingling is due to low calcium levels. Option A: The crash cart would be needed in respiratory distress but would not be the next action to take. Options C and D: Hypertension occurs in thyroid storm and the drainage would occur in hemorrhage.

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?

Correct! Wrong!

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 patient received surgery and chemotherapy for colon cancer, completing therapy 3 months previously, and she is now in remission. At a follow-up appointment, she complains of fatigue following activity and difficulty with concentration at her weekly bridge games. Which of the following explanations could account for her symptoms?

Correct! Wrong!

Three months after surgery and chemotherapy the patient is likely to be feeling the after-effects, which often includes anemia because of bone-marrow suppression. Option B: There is no evidence that the patient is immunosuppressed, and fatigue is not a typical symptom of immunosuppression. Options C and D: The information given does not indicate that depression or dehydration is a cause of her symptoms.

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