NCLEX RN Practice Questions 7 (Practice Mode) By RNpedia.Com

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.

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.

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.

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.

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.

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 .

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

The decrease in pulse can affect the cardiac output and lead to shock, which would take precedence over the other choices.

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.

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.

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.

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.

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.