NCLEX-RN Practice Test 17 — Questions and Answers
Question 1: A client with a pituitary tumor has had a transsphenoidal hypophysectomy. Which of the following interventions would be appropriate for this client?
- Place the client in Trendelenburg position for postural drainage
- Encourage coughing and deep breathing every 2 hours
- Elevate the head of the bed 30° (Correct answer)
- Encourage the Valsalva maneuver for bowel movements
Correct answer: Elevate the head of the bed 30°
After a transsphenoidal hypophysectomy, elevating the head of the bed to 30 degrees helps reduce intracranial pressure and promotes venous drainage from the surgical site. This position also decreases the risk of cerebrospinal fluid (CSF) leakage and minimizes pressure on the sella turcica. Activities that increase intracranial pressure, such as coughing or the Valsalva maneuver, are contraindicated.
Question 2: 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?
- The symptoms may be the result of anemia caused by chemotherapy. (Correct answer)
- The patient may be immunosuppressed.
- The patient may be depressed.
- The patient may be dehydrated.
Correct answer: The symptoms may be the result of anemia caused by chemotherapy.
Chemotherapy often suppresses bone marrow function, leading to decreased production of red blood cells and subsequent anemia. Anemia causes fatigue and difficulty with concentration due to reduced oxygen delivery to tissues, including the brain. These symptoms can persist for months after chemotherapy completion as the body recovers, making it a plausible explanation.
Question 3: 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?
- The client collects stamps as a hobby.
- The client recently lost his job as a postal worker.
- The client had radiation for treatment of Hodgkin’s disease as a teenager. (Correct answer)
- The client’s brother had leukemia as a child.
Correct answer: The client had radiation for treatment of Hodgkin’s disease as a teenager.
Prior radiation therapy, especially for conditions like Hodgkin's disease, is a known risk factor for developing secondary cancers, including acute leukemia, years later. Radiation can damage bone marrow stem cells, increasing the risk of malignant transformation. Inquiring about such a history is crucial for assessing potential risk factors for acute leukemia.
Question 4: Which of the following would be the priority nursing diagnosis for the adult client with acute leukemia?
- Oral mucous membrane, altered related to chemotherapy
- Risk for injury related to thrombocytopenia (Correct answer)
- Fatigue related to the disease process
- Interrupted family processes related to life-threatening illness of a family member
Correct answer: Risk for injury related to thrombocytopenia
Acute leukemia often leads to severe bone marrow suppression, resulting in thrombocytopenia (low platelet count). Thrombocytopenia significantly increases the risk of bleeding and hemorrhage, which can be life-threatening. Therefore, preventing injury and managing bleeding risk is a top priority in the nursing care of an adult client with acute leukemia.
Question 5: 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?
- Ask the patient to lie down on the exam table.
- Draw blood for chemistry panel and arterial blood gas (ABG).
- Send the patient for a chest x-ray.
- Check blood pressure. (Correct answer)
Correct answer: Check blood pressure.
For a patient with congestive heart failure complaining of dyspnea, checking blood pressure is a crucial initial assessment. It provides immediate information about the patient's hemodynamic status, helping to determine the severity of the heart failure exacerbation and guide subsequent interventions. Assessing vital signs is a foundational first step in any acute presentation.
Question 6: 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?
- BP 146/88
- Respirations 28 shallow (Correct answer)
- Weight gain of 10 pounds in 6 months
- Pink complexion
Correct answer: Respirations 28 shallow
Anemia reduces the oxygen-carrying capacity of the blood, meaning less oxygen reaches the body's tissues. To compensate for this decreased oxygen delivery, the body increases the respiratory rate to try and take in more oxygen. Therefore, tachypnea (respirations 28 shallow) is a direct clinical manifestation indicative of the body's compensatory response to anemia.
Question 7: 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.
- Weight loss.
- Increased clotting time. (Correct answer)
- Hypertension. (Correct answer)
- Headaches. (Correct answer)
Correct answer: Increased clotting time.
Polycythemia vera is characterized by an overproduction of all blood cell lines, including platelets. Despite the high platelet count, these platelets are often dysfunctional, a condition known as qualitative platelet defect. This dysfunction impairs their ability to form a proper clot, leading to an increased bleeding tendency and, consequently, a prolonged bleeding time. In some contexts, this impaired hemostasis might be referred to as an 'increased clotting time'.
Question 8: 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?
- Change the disposable mask immediately after use.
- Change gloves immediately after use. (Correct answer)
- Minimize patient contact.
- Minimize conversation with the patient.
Correct answer: Change gloves immediately after use.
Neutropenic patients have a severely compromised immune system, making them highly susceptible to infections. Changing gloves immediately after use, along with meticulous hand hygiene, is a fundamental infection control practice. This action prevents the transmission of pathogens and minimizes the risk of introducing bacteria or other microorganisms to the vulnerable patient, thereby protecting them from infection.
Question 9: 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?
- “Stop taking the nitroglycerin and see if the headaches improve.”
- “Go to the emergency department to be checked because nitroglycerin can cause bleeding in the brain.”
- “Headaches are a frequent side effect of nitroglycerine because it causes vasodilation.” (Correct answer)
- “The headaches are unlikely to be related to the nitroglycerin, so you should see your doctor for further investigation.”
Correct answer: “Headaches are a frequent side effect of nitroglycerine because it causes vasodilation.”
Nitroglycerin is a potent vasodilator, meaning it widens blood vessels throughout the body, including those in the brain. This vasodilation leads to increased blood flow and pressure within the cerebral vasculature, which is perceived as a headache. Headaches are a common and expected side effect of nitroglycerin, and patients should be educated about this rather than discontinuing the medication or seeking emergency care.
Question 10: Which of the following terms refer to the degree to which an instrument measures what it is supposed to be measure?
- Validity (Correct answer)
- Reliability
- Meaningfulness
- Sensitivity
Correct answer: Validity
Validity refers to the degree to which a research instrument or test accurately measures what it is intended to measure. If an instrument is valid, it means it is truly assessing the concept or variable it claims to be assessing. For example, a blood pressure cuff is valid if it accurately measures blood pressure, not just arm circumference.
Question 11: He plans for his sampling method. Which sampling method gives equal chance to all units in the population to get picked?
- Random (Correct answer)
- Accidental
- Quota
- Judgment
Correct answer: Random
A random sampling method ensures that every individual or unit in the target population has an equal and independent chance of being selected for the sample. This approach helps to minimize bias and increases the generalizability of the study findings to the larger population. It is a cornerstone of quantitative research for achieving representative samples.
Question 12: Raphael is interested to learn more about transcultural nursing because he is assigned at the family suites where most patients come from different cultures and countries. Which of the following designs is appropriate for this study?
- Grounded theory
- Ethnography (Correct answer)
- Case study
- Phenomenology
Correct answer: Ethnography
Ethnography is a qualitative research design specifically focused on exploring and describing the culture, beliefs, values, and practices of a particular group or community. Since Raphael is interested in transcultural nursing and patients from different cultures, ethnography is the most appropriate design to understand and interpret these cultural phenomena. It involves immersion in the cultural setting to gain an in-depth perspective.
Question 13: The nursing theorist who developed transcultural nursing theory is
- Dorothea Orem
- Madeleine Leininger (Correct answer)
- Betty Newman
- Sr. Callista Roy
Correct answer: Madeleine Leininger
Madeleine Leininger is widely recognized as the founder of transcultural nursing, developing the 'Culture Care Diversity and Universality Theory.' Her theory emphasizes the importance of understanding cultural differences and similarities in patient care to provide culturally congruent and competent nursing. Her work laid the foundation for culturally sensitive healthcare practices.
Question 14: As a manager, she focuses her energy on both the quality of services rendered to the patients as well as the welfare of the staff of her unit. Which of the following management styles does she adopt?
- Country club management
- Organization man management
- Team management (Correct answer)
- Authority-obedience management
Correct answer: Team management
Team management, according to Blake and Mouton's Managerial Grid, is characterized by a high concern for both people (welfare of staff) and production (quality of services). A manager adopting this style fosters a positive work environment while also striving for high performance and quality outcomes. This approach promotes collaboration and mutual respect to achieve organizational goals.
Question 15: She notes that there is an increasing unrest of the staff due to fatigue brought about by shortage of staff. Which action is a priority?
- Evaluate the overall result of the unrest
- Initiate a group interaction (Correct answer)
- Develop a plan and implement it
- Identify external and internal forces.
Correct answer: Initiate a group interaction
When staff unrest arises from issues like fatigue and shortage, the priority is to address the underlying concerns directly and collaboratively. Initiating a group interaction, such as a meeting or discussion, allows staff to voice their concerns, feel heard, and participate in finding solutions. This immediate action fosters communication and can de-escalate the situation before developing a formal plan.
Question 16: Kevin is a member of the Nursing Research Council of the hospital. His first assignment is to determine the level of patient satisfaction on the care they received from the hospital. He plans to include all adult patients admitted from April to May, with average length of stay of 3-4 days, first admission, and with no complications. Which of the following is an extraneous variable of the study?
- Date of admission
- Age of patients (Correct answer)
- Length of stay
- Absence of complications
Correct answer: Age of patients
An extraneous variable is a variable that is not the independent or dependent variable but could potentially affect the outcome of the study. In this study, Kevin is including adult patients, but he has not specified a narrow age range. Therefore, the varying ages within the 'adult' category could influence patient satisfaction, making age an extraneous variable that needs to be controlled or accounted for.
NCLEX-RN Practice Test 17
A client with a pituitary tumor has had a transsphenoidal hypophysectomy.
Which of the following interventions would be appropriate for this client?