NCLEX-RN Practice Test 17

Question 1

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

Accepted Answer

Elevate the head of the bed 30°

Answer

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?

Accepted Answer

The symptoms may be the result of anemia caused by chemotherapy.

Answer

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?

Accepted Answer

The client had radiation for treatment of Hodgkin’s disease as a teenager.

Answer

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?

Accepted Answer

Risk for injury related to thrombocytopenia

Answer

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?

Accepted Answer

Check blood pressure.

Answer

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.

NCLEX Practice Test

NCLEX Practice Test

NCLEX-RN Practice Test 17