NCLEX Practice Test Quiz

1. A nurse tells a physician the concern that a patient has grown a pulmonary embolism. Which symptom has the nurse most likely observed?

The patient is somnolent with decreased response to the family.

The patient suddenly complains of chest pain and shortness of breath.

The patient has developed a wet cough, and the nurse hears crackles during the auscultation of the lungs.

The patient has a fever, chills, and loss of appetite.

The nurse most likely observed the symptom of the patient suddenly complaining of chest pain and shortness of breath. This is a common symptom of a pulmonary embolism, which occurs when a blood clot blocks one of the arteries in the lungs. The sudden onset of chest pain and shortness of breath is a result of the restricted blood flow to the lungs. It is important for the nurse to inform the physician about this concern so that appropriate diagnostic tests and treatment can be initiated.

Explanation

The nurse most likely observed the symptom of the patient suddenly complaining of chest pain and shortness of breath. This is a common symptom of a pulmonary embolism, which occurs when a blood clot blocks one of the arteries in the lungs. The sudden onset of chest pain and shortness of breath is a result of the restricted blood flow to the lungs. It is important for the nurse to inform the physician about this concern so that appropriate diagnostic tests and treatment can be initiated.

2. A patient is about to go for bone marrow aspiration and biopsy and expresses fear and anxiety about the procedure. Which is the most effective nursing response?

Warn the patient to stay very still because the smallest movement will increase her pain.

Encourage the family to stay in the room for the procedure.

Stay with the patient and focus on slow. deep breathing for relaxation.

Delay the procedure to allow the patient to deal with her feelings.

The most effective nursing response in this situation is to stay with the patient and focus on slow, deep breathing for relaxation. This response acknowledges the patient's fear and anxiety and provides support by staying by their side. Encouraging slow, deep breathing can help the patient relax and reduce their anxiety before the procedure.

Explanation

The most effective nursing response in this situation is to stay with the patient and focus on slow, deep breathing for relaxation. This response acknowledges the patient's fear and anxiety and provides support by staying by their side. Encouraging slow, deep breathing can help the patient relax and reduce their anxiety before the procedure.

3. A patient is undergoing the induction stage of treatment for leukemia. The nurse tells family members about infectious precautions. Which statement by family members indicates that the family requires more education?

We will bring in books and magazines for entertainment.

We will bring in personal care items for comfort.

We will bring in fresh flowers to brighten the room.

We will bring in family pictures and get well cards.

The family members' statement of bringing in fresh flowers to brighten the room indicates that they require more education. During the induction stage of treatment for leukemia, the patient's immune system is compromised, making them more susceptible to infections. Fresh flowers can harbor bacteria and other pathogens, increasing the risk of infection for the patient. Therefore, it is important to educate the family members about the need to avoid bringing in fresh flowers and other items that may introduce potential sources of infection.

Explanation

The family members' statement of bringing in fresh flowers to brighten the room indicates that they require more education. During the induction stage of treatment for leukemia, the patient's immune system is compromised, making them more susceptible to infections. Fresh flowers can harbor bacteria and other pathogens, increasing the risk of infection for the patient. Therefore, it is important to educate the family members about the need to avoid bringing in fresh flowers and other items that may introduce potential sources of infection.

4. A nurse caring for several patients in the cardiac unit is informed that one is scheduled for implantation of an automatic internal cardioverter-defibrillator. Which patient is most likely to have this procedure?

A patient admitted for myocardial infarction without cardiac muscle damage.

A post-operative coronary bypass patient. Recovering on schedule.

A patient with a history of ventricular tachycardia and syncopal episodes.

A patient with a history of atrial tachycardia and fatigue.

The correct answer is a patient with a history of ventricular tachycardia and syncopal episodes. An automatic internal cardioverter-defibrillator (AICD) is typically implanted in patients who are at high risk for life-threatening ventricular arrhythmias. Ventricular tachycardia is a serious arrhythmia that can lead to sudden cardiac arrest, and syncopal episodes indicate a loss of consciousness, which can be caused by arrhythmias. Therefore, a patient with a history of ventricular tachycardia and syncopal episodes is the most likely candidate for an AICD implantation.

Explanation

The correct answer is a patient with a history of ventricular tachycardia and syncopal episodes. An automatic internal cardioverter-defibrillator (AICD) is typically implanted in patients who are at high risk for life-threatening ventricular arrhythmias. Ventricular tachycardia is a serious arrhythmia that can lead to sudden cardiac arrest, and syncopal episodes indicate a loss of consciousness, which can be caused by arrhythmias. Therefore, a patient with a history of ventricular tachycardia and syncopal episodes is the most likely candidate for an AICD implantation.

5. A patient has been scheduled for a magnetic resonance imaging (MRI) scan for suspected lung cancer. Which is a contraindication to the study for this patient?

The patient is allergic to shellfish.

The patient has a pacemaker.

The patient suffers from claustrophobia.

The patient takes antipsychotic medication.

Having a pacemaker is a contraindication for a patient undergoing a magnetic resonance imaging (MRI) scan. The strong magnetic field generated during an MRI can interfere with the functioning of the pacemaker, potentially causing harm to the patient. Therefore, it is important to avoid MRI scans for patients with pacemakers and explore alternative imaging methods.

Explanation

Having a pacemaker is a contraindication for a patient undergoing a magnetic resonance imaging (MRI) scan. The strong magnetic field generated during an MRI can interfere with the functioning of the pacemaker, potentially causing harm to the patient. Therefore, it is important to avoid MRI scans for patients with pacemakers and explore alternative imaging methods.

6. A patient arrives at the emergency department with abdominal pain. Workup shows the presence of a frequent enlarging abdominal aortic aneurysm. Which action should the nurse expect?

The patient will be admitted to the medical unit for observation and medication.

The patient will be admitted to the day surgery unit for sclerotherapy.

The patient will be admitted to the surgical unit, and resection will be scheduled.

The patient will be discharged home to follow up with his cardiologist in 24 hours.

An abdominal aortic aneurysm is a serious condition that requires surgical intervention to prevent rupture. The patient will be admitted to the surgical unit to prepare for the resection of the aneurysm. This is the appropriate action to take in order to address the patient's condition and prevent further complications.

Explanation

An abdominal aortic aneurysm is a serious condition that requires surgical intervention to prevent rupture. The patient will be admitted to the surgical unit to prepare for the resection of the aneurysm. This is the appropriate action to take in order to address the patient's condition and prevent further complications.

7. A patient with leukemia is getting chemotherapy known to depress bone marrow. A CBC (complete blood count) shows a platelet count of 25.000/microliter. Which action related specifically to the platelet count has to be included in the nursing care plan?

Monitor for fever every 4 hours.

Require visitors to wear respiratory masks and protective clothing.

Consider transfusion of packed red blood cells.

Check for signs of bleeding, including examination of urine and stool for blood.

Given that the patient is receiving chemotherapy that depresses bone marrow, it is likely that their platelet count is low. Platelets are responsible for clotting and preventing bleeding, so a low platelet count puts the patient at risk for bleeding. Therefore, the nursing care plan should include checking for signs of bleeding, such as examining urine and stool for blood. This is important to monitor the patient's condition and take appropriate action if bleeding is detected.

Explanation

Given that the patient is receiving chemotherapy that depresses bone marrow, it is likely that their platelet count is low. Platelets are responsible for clotting and preventing bleeding, so a low platelet count puts the patient at risk for bleeding. Therefore, the nursing care plan should include checking for signs of bleeding, such as examining urine and stool for blood. This is important to monitor the patient's condition and take appropriate action if bleeding is detected.

8. A nurse is treating a patient with acute lymphoblastic leukemia (ALL). Which is the most likely age range of the patient?

3-10 years.

25-35 years.

45-55 years.

Over 60 years.

Acute lymphoblastic leukemia (ALL) is a type of cancer that commonly affects children. The peak incidence of ALL occurs between the ages of 2 and 5, with a smaller peak in older adults. Therefore, the most likely age range for a patient with ALL would be 3-10 years.

Explanation

Acute lymphoblastic leukemia (ALL) is a type of cancer that commonly affects children. The peak incidence of ALL occurs between the ages of 2 and 5, with a smaller peak in older adults. Therefore, the most likely age range for a patient with ALL would be 3-10 years.

9. The Hodgkin’s disease patient tells in the question above undergoes a lymph node biopsy for definitive diagnosis. If the diagnosis of Hodgkin’s disease were right. which cell would the pathologist expect to find?

Reed-Sternberg cells.

Lymphoblastic cells.

Gaucher’s cells.

Rieder’s cells

The correct answer is Reed-Sternberg cells. Reed-Sternberg cells are large, abnormal cells that are characteristic of Hodgkin's disease. They are found in the lymph nodes during a biopsy and their presence confirms the diagnosis of Hodgkin's disease. Lymphoblastic cells are immature lymphocytes and are not specific to Hodgkin's disease. Gaucher's cells are associated with Gaucher's disease, a rare genetic disorder. Rieder's cells are not a known cell type associated with any specific disease.

Explanation

The correct answer is Reed-Sternberg cells. Reed-Sternberg cells are large, abnormal cells that are characteristic of Hodgkin's disease. They are found in the lymph nodes during a biopsy and their presence confirms the diagnosis of Hodgkin's disease. Lymphoblastic cells are immature lymphocytes and are not specific to Hodgkin's disease. Gaucher's cells are associated with Gaucher's disease, a rare genetic disorder. Rieder's cells are not a known cell type associated with any specific disease.

10. A patient is admitted to the oncology unit for the test of suspected Hodgkin's disease. Which symptom is typical of Hodgkin's disease?

Painful cervical lymph nodes.

Night sweats and fatigue.

Nausea and vomiting.

Weight gain.

Night sweats and fatigue are typical symptoms of Hodgkin's disease. Hodgkin's disease is a type of lymphoma that affects the lymphatic system. Night sweats, which are excessive sweating during sleep, and fatigue, which is extreme tiredness or lack of energy, are common symptoms experienced by individuals with Hodgkin's disease. These symptoms can be caused by the body's immune response to the disease and the release of certain chemicals. Therefore, night sweats and fatigue are indicative of Hodgkin's disease.

Explanation

Night sweats and fatigue are typical symptoms of Hodgkin's disease. Hodgkin's disease is a type of lymphoma that affects the lymphatic system. Night sweats, which are excessive sweating during sleep, and fatigue, which is extreme tiredness or lack of energy, are common symptoms experienced by individuals with Hodgkin's disease. These symptoms can be caused by the body's immune response to the disease and the release of certain chemicals. Therefore, night sweats and fatigue are indicative of Hodgkin's disease.