NCLEX Practice Exam 41 (10 Questions)

1. A hospitalized patient is receiving packed red blood cells (PRBCs) for treatment of severe anemia. Which of the following is the most accurate statement?

Transfusion reaction is most likely immediately after the infusion is completed.

PRBCs are best infused slowly through a 20g. IV catheter.

PRBCs should be flushed with a 5% dextrose solution.

A nurse should remain in the room during the first 15 minutes of infusion.

Transfusion reaction is most likely during the first 15 minutes of infusion. and a nurse should be present during this period. PRBCs should be infused through a 19g or larger IV catheter to avoid slow flow. which can cause clotting. PRBCs must be flushed with 0.45% normal saline solution. Other intravenous solutions will hemolyze the cells.

Explanation

Transfusion reaction is most likely during the first 15 minutes of infusion. and a nurse should be present during this period. PRBCs should be infused through a 19g or larger IV catheter to avoid slow flow. which can cause clotting. PRBCs must be flushed with 0.45% normal saline solution. Other intravenous solutions will hemolyze the cells.

2. A clinic patient has recently been prescribed nitroglycerin for treatment of angina. He calls the nurse complaining of frequent headaches. Which of the following responses to the patient is correct?

“Stop taking the nitroglycerin and see if the headaches improve.”

“Go to the emergency department to be checked because nitroglycerin can cause bleeding in the brain.”

“Headaches are a frequent side effect of nitroglycerine because it causes vasodilation.”

“The headaches are unlikely to be related to the nitroglycerin. so you should see your doctor for further investigation.”

Nitroglycerin is a potent vasodilator and often produces unwanted effects such as headache. dizziness. and hypotension. Patients should be counseled. and the dose titrated. to minimize these effects. In spite of the side effects. nitroglycerine is effective at reducing myocardial oxygen consumption and increasing blood flow. The patient should not stop the medication. Nitroglycerine does not cause bleeding in the brain.

Explanation

Nitroglycerin is a potent vasodilator and often produces unwanted effects such as headache. dizziness. and hypotension. Patients should be counseled. and the dose titrated. to minimize these effects. In spite of the side effects. nitroglycerine is effective at reducing myocardial oxygen consumption and increasing blood flow. The patient should not stop the medication. Nitroglycerine does not cause bleeding in the brain.

3. 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?

The diet is providing adequate sources of iron and requires no changes.

The patient should add meat to her diet; a vegetarian diet is not advised.

The patient should use iron cookware to prepare foods. such as dark green. leafy vegetables and legumes. which are high in iron.

A cup of coffee or tea should be added to every meal.

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. In addition. dark green leafy vegetables. such as spinach and kale. and legumes are high in iron. Mild anemia does not require that animal sources of iron be added to the diet. Many non-animal sources are available. Coffee and tea increase gastrointestinal activity and inhibit absorption of iron.

Explanation

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. In addition. dark green leafy vegetables. such as spinach and kale. and legumes are high in iron. Mild anemia does not require that animal sources of iron be added to the diet. Many non-animal sources are available. Coffee and tea increase gastrointestinal activity and inhibit absorption of iron.

4. A mother complains to the clinic nurse that her 2 ½-year-old son is not yet toilet trained. She is particularly concerned that. although he reliably uses the potty seat for bowel movements. he isn't able to hold his urine for long periods. Which of the following statements by the nurse is correct?

The child should have been trained by age 2 and may have a psychological problem that is responsible for his “accidents.”

Bladder control is usually achieved before bowel control. and the child should be required to sit on the potty seat until he passes urine.

Bowel control is usually achieved before bladder control. and the average age for completion of toilet training varies widely from 24 to 36 months.

The child should be told “no” each time he wets so that he learns the behavior is unacceptable.

Toddlers typically learn bowel control before bladder control. with boys often taking longer to complete toilet training than girls. Many children are not trained until 36 months and this should not cause concern. Later training is rarely caused by psychological factors and is much more commonly related to individual developmental maturity. Reprimanding the child will not speed the process and may be confusing.

Explanation

Toddlers typically learn bowel control before bladder control. with boys often taking longer to complete toilet training than girls. Many children are not trained until 36 months and this should not cause concern. Later training is rarely caused by psychological factors and is much more commonly related to individual developmental maturity. Reprimanding the child will not speed the process and may be confusing.

5. An older patient asks a nurse to recommend strategies to prevent constipation. Which of the following suggestions would be helpful? Note: More than one answer may be correct.

Get moderate exercise for at least 30 minutes each day.

Drink 6-8 glasses of water each day.

Eat a diet high in fiber.

Take a mild laxative if you don’t have a bowel movement every day.

A daily bowel movement is not necessary if the patient is comfortable and the bowels move regularly. Moderate exercise. such as walking. encourages bowel health. as does generous water intake. A diet high in fiber is also helpful. Laxatives should be used as a last resort and should not be taken regularly. Over time. laxatives can desensitize the bowel and worsen constipation.

Explanation

A daily bowel movement is not necessary if the patient is comfortable and the bowels move regularly. Moderate exercise. such as walking. encourages bowel health. as does generous water intake. A diet high in fiber is also helpful. Laxatives should be used as a last resort and should not be taken regularly. Over time. laxatives can desensitize the bowel and worsen constipation.

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6. 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?

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

The patient may be immunosuppressed.

The patient may be depressed.

The patient may be dehydrated.

Three months after surgery and chemotherapy the patient is likely to be feeling the after-effects. which often includes anemia because of bone-marrow suppression. There is no evidence that the patient is immunosuppressed. and fatigue is not a typical symptom of immunosuppression. The information given does not indicate that depression or dehydration is a cause of her symptoms.

Explanation

Three months after surgery and chemotherapy the patient is likely to be feeling the after-effects. which often includes anemia because of bone-marrow suppression. There is no evidence that the patient is immunosuppressed. and fatigue is not a typical symptom of immunosuppression. The information given does not indicate that depression or dehydration is a cause of her symptoms.

7. Which of the following actions is NOT appropriate in the care of a 2-month-old infant?

Place the infant on her back for naps and bedtime.

Allow the infant to cry for 5 minutes before responding if she wakes during the night as she may fall back asleep.

Talk to the infant frequently and make eye contact to encourage language development.

Wait until at least 4 months to add infant cereals and strained fruits to the diet.

Infants under 6 months may not be able to sleep for long periods because their stomachs are too small to hold adequate nourishment to take them through the night. After 6 months. it may be helpful to let babies put themselves back to sleep after waking during the night. but not prior to 6 months. Infants should always be placed on their backs to sleep. Research has shown a dramatic decrease in sudden infant death syndrome (SIDS) with back sleeping. Eye contact and verbal engagement with infants are important to language development. The best diet for infants under 4 months of age is breast milk or infant formula.

Explanation

Infants under 6 months may not be able to sleep for long periods because their stomachs are too small to hold adequate nourishment to take them through the night. After 6 months. it may be helpful to let babies put themselves back to sleep after waking during the night. but not prior to 6 months. Infants should always be placed on their backs to sleep. Research has shown a dramatic decrease in sudden infant death syndrome (SIDS) with back sleeping. Eye contact and verbal engagement with infants are important to language development. The best diet for infants under 4 months of age is breast milk or infant formula.

8. 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?

Ask the patient to lie down on the exam table.

Draw blood for chemistry panel and arterial blood gas (ABG).

Send the patient for a chest x-ray.

Check blood pressure.

A patient with congestive heart failure and dyspnea may have pulmonary edema. which can cause severe hypertension. Therefore. taking the patient’s blood pressure should be the first action. Lying flat on the exam table would likely worsen the dyspnea. and the patient may not tolerate it. Blood draws for chemistry and ABG will be required. but not prior to the blood pressure assessment.

Explanation

A patient with congestive heart failure and dyspnea may have pulmonary edema. which can cause severe hypertension. Therefore. taking the patient’s blood pressure should be the first action. Lying flat on the exam table would likely worsen the dyspnea. and the patient may not tolerate it. Blood draws for chemistry and ABG will be required. but not prior to the blood pressure assessment.

9. A child is admitted to the hospital with suspected rheumatic fever. Which of the following observations is NOT confirming of the diagnosis?

A reddened rash visible over the trunk and extremities.

A history of sore throat that was self-limited in the past month.

A negative antistreptolysin O titer.

An unexplained fever.

Rheumatic fever is caused by an untreated group A B hemolytic Streptococcus infection in the previous 2-6 weeks. confirmed by a positive antistreptolysin O titer. Rheumatic fever is characterized by a red rash over the trunk and extremities as well as fever and other symptoms.

Explanation

Rheumatic fever is caused by an untreated group A B hemolytic Streptococcus infection in the previous 2-6 weeks. confirmed by a positive antistreptolysin O titer. Rheumatic fever is characterized by a red rash over the trunk and extremities as well as fever and other symptoms.

10. The mother of a 14-month-old child reports to the nurse that her child will not fall asleep at night without a bottle of milk in the crib and often wakes during the night asking for another. Which of the following instructions by the nurse is correct?

Allow the child to have the bottle at bedtime. but withhold the one later in the night.

Put juice in the bottle instead of milk.

Give only a bottle of water at bedtime.

Do not allow bottles in the crib.

Babies and toddlers should not fall asleep with bottles containing liquid other than plain water due to the risk of dental decay. Sugars in milk or juice remain in the mouth during sleep and cause caries. even in teeth that have not yet erupted. When water is substituted for milk or juice. babies will often lose interest in the bottle at night.

Explanation

Babies and toddlers should not fall asleep with bottles containing liquid other than plain water due to the risk of dental decay. Sugars in milk or juice remain in the mouth during sleep and cause caries. even in teeth that have not yet erupted. When water is substituted for milk or juice. babies will often lose interest in the bottle at night.