NCLEX-RN Practice Test 19
A 25-year-old male is admitted in sickle cell crisis. Which of the following interventions would be of highest priority for this client?
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.
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:
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 nurse is caring for a patient with acute lymphoblastic leukemia (ALL). Which of the following is the most likely age range of the patient?
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.
Which of the following foods would the nurse encourage the client in sickle cell crisis to eat?
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.
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?
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 client has autoimmune thrombocytopenic purpura. To determine the client’s response to treatment, the nurse would monitor:
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.
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?
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.
Clients with sickle cell anemia are taught to avoid activities that cause hypoxia and hypoxemia. Which of the following activities would the nurse recommend?
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.
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?
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.
St. Raphael Medical Center just opened its new Performance Improvement Department. Ms. Valencia is appointed as the Quality Control Officer. She commits herself to her new role and plans her strategies to realize the goals and objectives of the department. Which of the following is a primary task that they should perform to have an effective control system?
Identify the values of the department will set the guiding principles within which the department will operate its activities
Ms. Valencia develops the standards to be followed. Among the following standards, which is considered as a structure standard?
Structure standards include management system, facilities, equipment, materials needed to deliver care to patients. Rotation of duty is a management system.
When she presents the nursing procedures to be followed, she refers to what type of standards?
Process standards include care plans, nursing procedure to be done to address the needs of the patients.
The following are basic steps in the controlling process of the department. Which of the following is NOT included?
This is a step in a quality control process and not a basic step in the control process.
Which of the following statements refers to criteria?
Criteria are specific characteristics used to measure the standard of care.
She wants to ensure that every task is carried out as planned. Which of the following tasks is NOT included in the controlling process?
Instructing the members involves a directing function.
Ms. Valencia prepares the process standards. Which of the following is NOT a process standard?
This refers to an outcome standard, which is a result of the care that is rendered to the patient.