NCLEX RN Practice Questions 7 (Practice Mode) By RNpedia.Com
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- 1.
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?
- A.
Body temperature of 99°F or less
- B.
Toes moved in active range of motion
- C.
Sensation reported when soles of feet are touched
- D.
Capillary refill of < 3 seconds
Correct Answer
D. Capillary refill of < 3 secondsExplanation
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. Body temperature, motion, and sensation would not give information regarding peripheral circulation; therefore, body temperature of 99°F or less , toes moved in active range of motion, and sensation reported when soles of feet are touched are incorrect.Rate this question:
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- 2.
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?
- A.
Side-lying with knees flexed
- B.
Knee-chest
- C.
High Fowler’s with knees flexed
- D.
Semi-Fowler’s with legs extended on the bed
Correct Answer
D. Semi-Fowler’s with legs extended on the bedExplanation
Placing the client in semi-Fowler’s position provides the best oxygenation for this client. Flexion of the hips and knees, which includes the knee-chest position, impedes circulation and is not correct positioning for this client.Rate this question:
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- 3.
A 25-year-old male is admitted in sickle cell crisis. Which of the following interventions would be of highest priority for this client?
- A.
Taking hourly blood pressures with mechanical cuff
- B.
Encouraging fluid intake of at least 200mL per hour
- C.
Position in high Fowler’s with knee gatch raised
- D.
Administering Tylenol as ordered
Correct Answer
B. Encouraging fluid intake of at least 200mL per hourExplanation
It is important to keep the client in sickle cell crisis hydrated to prevent further sickling of the blood. Taking hourly blood pressures with mechanical cuff is incorrect because a mechanical cuff places too much pressure on the arm. Position in high Fowler’s with knee gatch raised is incorrect because raising the knee gatch impedes circulation. Administering Tylenol as ordered is incorrect because Tylenol is too mild an analgesic for the client in crisis.Rate this question:
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- 4.
Which of the following foods would the nurse encourage the client in sickle cell crisis to eat?
- A.
Peaches
- B.
Cottage cheese
- C.
Popsicle
- D.
Lima beans
Correct Answer
C. PopsicleExplanation
Hydration is important in the client with sickle cell disease to prevent thrombus formation. Popsicles, gelatin, juice, and pudding have high fluid content. The foods in peaches , cottage cheese , and lima beans do not aid in hydration and are, therefore, incorrect.Rate this question:
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- 5.
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.
- A.
Adjust the room temperature
- B.
Give a bolus of IV fluids
- C.
Start O2
- D.
Administer meperidine (Demerol) 75mg IV push
Correct Answer
C. Start O2Explanation
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. Adjusting the room temperature is incorrect because although a warm environment reduces pain and minimizes sickling, it would not be a priority. Giving a bolus of IV fluids is incorrect because although hydration is important, it would not require a bolus. Administering meperidine (Demerol) 75mg IV push is incorrect because Demerol is acidifying to the blood and increases sickling.Rate this question:
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- 6.
The nurse is instructing a client with iron-deficiency anemia. Which of the following meal plans would the nurse expect the client to select?
- A.
Roast beef, gelatin salad, green beans, and peach pie
- B.
Chicken salad sandwich, coleslaw, French fries, ice cream
- C.
Egg salad on wheat bread, carrot sticks, lettuce salad, raisin pie
- D.
Pork chop, creamed potatoes, corn, and coconut cake
Correct Answer
C. Egg salad on wheat bread, carrot sticks, lettuce salad, raisin pieExplanation
Egg yolks, wheat bread, carrots, raisins, and green, leafy vegetables are all high in iron, which is an important mineral for this client. Roast beef, cabbage, and pork chops are also high in iron, but the side dishes accompanying these choices are not.Rate this question:
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- 7.
Clients with sickle cell anemia are taught to avoid activities that cause hypoxia and hypoxemia. Which of the following activities would the nurse recommend?
- A.
A family vacation in the Rocky Mountains
- B.
Chaperoning the local boys club on a snow-skiing trip
- C.
Traveling by airplane for business trips
- D.
A bus trip to the Museum of Natural History
Correct Answer
D. A bus trip to the Museum of Natural HistoryExplanation
Taking a trip to the museum is the only answer that does not pose a threat. A family vacation in the Rocky Mountains at high altitudes, cold temperatures, and airplane travel can cause sickling episodes and should be avoided.Rate this question:
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- 8.
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?
- A.
Palpate the spleen
- B.
Take the blood pressure
- C.
Examine the feet for petechiae
- D.
Examine the tongue
Correct Answer
D. Examine the tongueExplanation
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, splenomegaly, and blood pressure changes do not occur, making palpating the spleen ,taking the blood pressure and examining the feet for petechiae incorrect.Rate this question:
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- 9.
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?
- A.
Conjunctiva of the eye
- B.
Soles of the feet
- C.
Roof of the mouth
- D.
Shins
Correct Answer
C. Roof of the mouthExplanation
The oral mucosa and hard palate (roof of the mouth) are the best indicators of jaundice in dark-skinned persons. The conjunctiva can have normal deposits of fat, which give a yellowish hue; thus, conjunctiva of the eye is incorrect. The soles of the feet can be yellow if they are calloused, making soles of the feet incorrect; the shins would be an area of darker pigment, so shins is incorrect.Rate this question:
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- 10.
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?
- A.
BP 146/88
- B.
Respirations 28 shallow
- C.
Weight gain of 10 pounds in 6 months
- D.
Pink complexion
Correct Answer
B. Respirations 28 shallowExplanation
When there are fewer red blood cells, there is less hemoglobin and less oxygen. Therefore, the client is often short of breath, as indicated in respirations, 28, shallow . The client with anemia is often pale in color, has weight loss, and may be hypotensive. BP of 146/88 , weight gain of 10 pounds in 6 months , and pink complexion are within normal and, therefore, are incorrect.Rate this question:
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- 11.
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?
- A.
"I will drink 500mL of fluid or less each day."
- B.
"I will wear support hose when I am up."
- C.
"I will use an electric razor for shaving."
- D.
"I will eat foods low in iron."
Correct Answer
A. "I will drink 500mL of fluid or less each day."Explanation
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. Wearing support hose when I am up, using an electric razor for shaving, and eating foods low in iron are incorrect because they all contribute to the prevention of complications. 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.Rate this question:
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- 12.
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?
- A.
The client collects stamps as a hobby.
- B.
The client recently lost his job as a postal worker.
- C.
The client had radiation for treatment of Hodgkin’s disease as a teenager
- D.
The client’s brother had leukemia as a child.
Correct Answer
C. The client had radiation for treatment of Hodgkin’s disease as a teenagerExplanation
Radiation treatment for other types of cancer can result in leukemia. Some hobbies and occupations involving chemicals are linked to leukemia, but not the ones in these answers; therefore, collecting stamps as a hobby and losing job as a postal worker are incorrect. The client’s brother had leukemia as a child is incorrect because the incidence of leukemia is higher in twins than in siblings.Rate this question:
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- 13.
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?
- A.
The abdomen
- B.
The thorax
- C.
The earlobes
- D.
The soles of the feet
Correct Answer
D. The soles of the feetExplanation
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. The abdomen, thorax , and earlobes are incorrect because the skin might be too dark to make an assessment.Rate this question:
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- 14.
A client with acute leukemia is admitted to the oncology unit. Which of the following would be most important for the nurse to inquire?
- A.
"Have you noticed a change in sleeping habits recently?"
- B.
"Have you had a respiratory infection in the last 6 months?"
- C.
"Have you lost weight recently?"
- D.
"Have you noticed changes in your alertness?"
Correct Answer
B. "Have you had a respiratory infection in the last 6 months?"Explanation
The client with leukemia is at risk for infection and has often had recurrent respiratory infections during the previous 6 months. Insomnolence, weight loss, and a decrease in alertness also occur in leukemia, but bleeding tendencies and infections are the primary clinical manifestations.Rate this question:
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- 15.
Which of the following would be the priority nursing diagnosis for the adult client with acute leukemia?
- A.
Oral mucous membrane, altered related to chemotherapy
- B.
Risk for injury related to thrombocytopenia
- C.
Fatigue related to the disease process
- D.
Interrupted family processes related to life-threatening illness of a family member
Correct Answer
B. Risk for injury related to thrombocytopeniaExplanation
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 : Oral mucous membrane, altered related to chemotherapy ,Fatigue related to the disease process and Interrupted family processes related to life-threatening illness of a family member .Rate this question:
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- 16.
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?
- A.
Sexual dysfunction related to radiation therapy
- B.
Anticipatory grieving related to terminal illness
- C.
Tissue integrity related to prolonged bed rest
- D.
Fatigue related to chemotherapy
Correct Answer
A. Sexual dysfunction related to radiation therapyExplanation
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. Anticipatory grieving related to terminal illness, Tissue integrity related to prolonged bed rest, and Fatigue related to chemotherapy are incorrect because they are of lesser priority.Rate this question:
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- 17.
A client has autoimmune thrombocytopenic purpura. To determine the client’s response to treatment, the nurse would monitor:
- A.
Platelet count
- B.
White blood cell count
- C.
Potassium levels
- D.
Partial prothrombin time (PTT)
Correct Answer
A. Platelet countExplanation
Clients with autoimmune thrombocytopenic purpura (ATP) have low platelet counts, making platelet count the correct answer. White cell counts, potassium levels, and PTT are not affected in ATP.Rate this question:
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- 18.
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:
- A.
Bleeding precautions
- B.
Prevention of falls
- C.
Oxygen therapy
- D.
Conservation of energy
Correct Answer
A. Bleeding precautionsExplanation
The normal platelet count is 120,000–400, Bleeding occurs in clients with low platelets. The priority is to prevent and minimize bleeding. Oxygenation in oxygen therapy is important, but platelets do not carry oxygen. Prevention of falls and conservation of energy are of lesser priority and are incorrect in this instance.Rate this question:
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- 19.
A client with a pituitary tumor has had a transphenoidal hyposphectomy. Which of the following interventions would be appropriate for this client?
- A.
Place the client in Trendelenburg position for postural drainage
- B.
Encourage coughing and deep breathing every 2 hours
- C.
Elevate the head of the bed 30°
- D.
Encourage the Valsalva maneuver for bowel movements
Correct Answer
C. Elevate the head of the bed 30°Explanation
Elevating the head of the bed 30° avoids pressure on the sella turcica and alleviates headaches. Trendelenburg, Valsalva maneuver, and coughing are incorrect because all increase the intracranial pressure.Rate this question:
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- 20.
The client with a history of diabetes insipidus is admitted with polyuria, polydipsia, and mental confusion. The priority intervention for this client is:
- A.
Measure the urinary output
- B.
Check the vital signs
- C.
Encourage increased fluid intake
- D.
Weigh the client
Correct Answer
B. Check the vital signsExplanation
The 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. Measuring the urinary output is important, but the stem already says that the client has polyuria, so measuring the urinary output is incorrect. Encouraging fluid intake will not correct the problem.Weighing the client is incorrect because it is not necessary at this time.Rate this question:
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- 21.
A client with hemophilia has a nosebleed. Which nursing action is most appropriate to control the bleeding?
- A.
Place the client in a sitting position with the head hyperextended
- B.
Pack the nares tightly with gauze to apply pressure to the source of bleeding
- C.
Pinch the soft lower part of the nose for a minimum of 5 minutes
- D.
Apply ice packs to the forehead and back of the neck
Correct Answer
C. Pinch the soft lower part of the nose for a minimum of 5 minutesExplanation
The client should be positioned upright and leaning forward, to prevent aspiration of blood. Placing the client in a sitting position with the head hyperextended , packing the nares tightly with gauze to apply pressure to the source of bleeding , and applying ice packs to the forehead and back of the neck are incorrect because 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.Rate this question:
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- 22.
A client has had a unilateral adrenalectomy to remove a tumor. To prevent complications, the most important measurement in the immediate post-operative period for the nurse to take is:
- A.
Blood pressure
- B.
Temperature
- C.
Output
- D.
Specific gravity
Correct Answer
A. Blood pressureExplanation
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, 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.Rate this question:
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- 23.
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?
- A.
Glucometer readings as ordered
- B.
Intake/output measurements
- C.
Sodium and potassium levels monitored
- D.
Daily weights
Correct Answer
A. Glucometer readings as orderedExplanation
IV glucocorticoids raise the glucose levels and often require coverage with insulin. Answer B is not necessary at this time, sodium and potassium levels would be monitored when the client is receiving mineral corticoids, and daily weights is unnecessary.Rate this question:
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- 24.
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?
- A.
Obtain a crash cart
- B.
Check the calcium level
- C.
Assess the dressing for drainage
- D.
Assess the blood pressure for hypertension
Correct Answer
B. Check the calcium levelExplanation
The parathyroid glands are responsible for calcium production and can be damaged during a thyroidectomy. The tingling is due to low calcium levels. The crash cart would be needed in respiratory distress but would not be the next action to take; thus, obtaining a crash cart is incorrect. Hypertension occurs in thyroid storm and the drainage would occur in hemorrhage, so assessing the dressing for drainage and assessing the blood pressure for hypertension are incorrect.Rate this question:
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- 25.
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?
- A.
Impaired physical mobility related to decreased endurance
- B.
Hypothermia r/t decreased metabolic rate
- C.
Disturbed thought processes r/t interstitial edema
- D.
Decreased cardiac output r/t bradycardia
Correct Answer
D. Decreased cardiac output r/t bradycardiaExplanation
The decrease in pulse can affect the cardiac output and lead to shock, which would take precedence over the other choices.Rate this question:
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Mar 21, 2023Quiz Edited by
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May 21, 2012Quiz Created by
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