NCLEX Practice Exam 44 (10 Questions)

1. A nurse is caring for a patient with a platelet count of 20.000/microliter. Which of the following is an important intervention?

Observe for evidence of spontaneous bleeding.

Limit visitors to family only.

Give aspirin in case of headaches.

Impose immune precautions.

Platelet counts under 30.000/microliter may cause spontaneous petechiae and bruising. particularly in the extremities. When the count falls below 15.000. spontaneous bleeding into the brain and internal organs may occur. Headaches may be a sign and should be watched for. Aspirin disables platelets and should never be used in the presence of thrombocytopenia. Thrombocytopenia does not compromise immunity. and there is no reason to limit visitors as long as any physical trauma is prevented.

Explanation

Platelet counts under 30.000/microliter may cause spontaneous petechiae and bruising. particularly in the extremities. When the count falls below 15.000. spontaneous bleeding into the brain and internal organs may occur. Headaches may be a sign and should be watched for. Aspirin disables platelets and should never be used in the presence of thrombocytopenia. Thrombocytopenia does not compromise immunity. and there is no reason to limit visitors as long as any physical trauma is prevented.

2. A patient at a mental health clinic is taking Haldol (haloperidol) for treatment of schizophrenia. She calls the clinic to report abnormal movements of her face and tongue. The nurse concludes that the patient is experiencing which of the following symptoms:

Co-morbid depression.

Psychotic hallucinations.

Negative symptoms of schizophrenia.

Tardive dyskinesia.

Abnormal facial movements and tongue protrusion in a patient taking haloperidol is most likely due to tardive dyskinesia. an adverse reaction to the antipsychotic. Depression may occur along with schizophrenia and would be characterized by such symptoms as loss of affect. appetite and/or sleep changes. and anhedonia. These depressive changes and lack of volition are part of the negative symptoms of schizophrenia. Psychotic hallucinations may be visual or auditory but do not include abnormal movements.

Explanation

Abnormal facial movements and tongue protrusion in a patient taking haloperidol is most likely due to tardive dyskinesia. an adverse reaction to the antipsychotic. Depression may occur along with schizophrenia and would be characterized by such symptoms as loss of affect. appetite and/or sleep changes. and anhedonia. These depressive changes and lack of volition are part of the negative symptoms of schizophrenia. Psychotic hallucinations may be visual or auditory but do not include abnormal movements.

3. A nurse is counseling patients at a health clinic on the importance of immunizations. Which of the following information is the most accurate regarding immunizations?

All infectious diseases can be prevented with proper immunization.

Immunizations provide natural immunity from disease.

Immunizations are risk-free and should be universally administered.

Immunization provides acquired immunity from some specific diseases.

Immunization is available for the prevention of some. but not all. specific diseases. This type of immunity is “acquired” by causing antibodies to form in response to a specific pathogen. Natural immunity is present at birth because the infant acquires maternal antibodies Immunization. like all medication. cannot be risk-free and should be considered based on the risk of the disease in question.

Explanation

Immunization is available for the prevention of some. but not all. specific diseases. This type of immunity is “acquired” by causing antibodies to form in response to a specific pathogen. Natural immunity is present at birth because the infant acquires maternal antibodies Immunization. like all medication. cannot be risk-free and should be considered based on the risk of the disease in question.

4. A patient is brought to the emergency department after a bee sting. The family reports a history of severe allergic reaction. and the patient appears to have some oral swelling. Which of the following is the most urgent nursing action?

Consult a physician.

Maintain a patent airway.

Administer epinephrine subcutaneously.

Administer diphenhydramine (Benadryl) orally.

The patient may be experiencing an anaphylactic reaction. The most urgent action is to maintain an airway. particularly with visible oral swelling. followed by the administration of epinephrine by subcutaneous injection. The physician will see the patient as soon as possible with the above actions underway. Oral diphenhydramine is indicated for mild allergic reactions and is not appropriate for anaphylaxis.

Explanation

The patient may be experiencing an anaphylactic reaction. The most urgent action is to maintain an airway. particularly with visible oral swelling. followed by the administration of epinephrine by subcutaneous injection. The physician will see the patient as soon as possible with the above actions underway. Oral diphenhydramine is indicated for mild allergic reactions and is not appropriate for anaphylaxis.

5. A patient who has received chemotherapy for cancer treatment is given an injection of Epoetin. Which of the following should reflect the findings in a complete blood count (CBC) drawn several days later?

An increase in neutrophil count.

An increase in hematocrit.

An increase in platelet count.

An increase in serum iron.

Epoetin is a form of erythropoietin. which stimulates the production of red blood cells. causing an increase in hematocrit. Epoetin is given to patients who are anemic. often as a result of chemotherapy treatment. Epoetin has no effect on neutrophils. platelets. or serum iron.

Explanation

Epoetin is a form of erythropoietin. which stimulates the production of red blood cells. causing an increase in hematocrit. Epoetin is given to patients who are anemic. often as a result of chemotherapy treatment. Epoetin has no effect on neutrophils. platelets. or serum iron.

6. A patient with newly diagnosed diabetes mellitus is learning to recognize the symptoms of hypoglycemia. Which of the following symptoms is indicative of hypoglycemia?

Polydipsia.

Confusion.

Blurred vision.

Polyphagia.

Hypoglycemia in diabetes mellitus causes confusion. indicating the need for carbohydrates. Polydipsia. blurred vision. and polyphagia are symptoms of hyperglycemia.

Explanation

Hypoglycemia in diabetes mellitus causes confusion. indicating the need for carbohydrates. Polydipsia. blurred vision. and polyphagia are symptoms of hyperglycemia.

7. A nurse is caring for patients in the oncology unit. Which of the following is the most important nursing action when caring for a neutropenic patient?

Change the disposable mask immediately after use.

Change gloves immediately after use.

Minimize patient contact.

Minimize conversation with the patient.

The neutropenic patient is at risk of infection. Changing gloves immediately after use protects patients from contamination with organisms picked up on hospital surfaces. This contamination can have serious consequences for an immunocompromised patient. Changing the respiratory mask is desirable. but not nearly as urgent as changing gloves. Minimizing contact and conversation are not necessary and may cause nursing staff to miss changes in the patient’s symptoms or condition.

Explanation

The neutropenic patient is at risk of infection. Changing gloves immediately after use protects patients from contamination with organisms picked up on hospital surfaces. This contamination can have serious consequences for an immunocompromised patient. Changing the respiratory mask is desirable. but not nearly as urgent as changing gloves. Minimizing contact and conversation are not necessary and may cause nursing staff to miss changes in the patient’s symptoms or condition.

8. A patient is admitted to the hospital with suspected polycythemia vera. Which of the following symptoms is consistent with the diagnosis? Select all that apply.

Weight loss.

Increased clotting time.

Hypertension.

Headaches.

Polycythemia vera is a condition in which the bone marrow produces too many red blood cells. This causes an increase in hematocrit and viscosity of the blood. Patients can experience headaches. dizziness. and visual disturbances. Cardiovascular effects include increased blood pressure and delayed clotting time. Weight loss is not a manifestation of polycythemia vera.

Explanation

Polycythemia vera is a condition in which the bone marrow produces too many red blood cells. This causes an increase in hematocrit and viscosity of the blood. Patients can experience headaches. dizziness. and visual disturbances. Cardiovascular effects include increased blood pressure and delayed clotting time. Weight loss is not a manifestation of polycythemia vera.

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9. A mother calls the clinic to report that her son has recently started medication to treat attention deficit/hyperactivity disorder (ADHD). The mother fears her son is experiencing side effects of the medicine. Which of the following side effects are typically related to medications used for ADHD? Note: More than one answer may be correct:

Poor appetite.

Insomnia.

Sleepiness.

Agitation.

ADHD in children is frequently treated with CNS stimulant medications. which increase focus and improve concentration. Children often experience insomnia. agitation. and decreased appetite. Sleepiness is not a side effect of stimulants.

Explanation

ADHD in children is frequently treated with CNS stimulant medications. which increase focus and improve concentration. Children often experience insomnia. agitation. and decreased appetite. Sleepiness is not a side effect of stimulants.

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10. A nurse in the emergency department assesses a patient who has been taking long-term corticosteroids to treat renal disease. Which of the following is a typical side effect of corticosteroid treatment? Note: More than one answer may be correct.

Hypertension.

Cushingoid features.

Hyponatremia.

Low serum albumin.

Side effects of corticosteroids include weight gain. fluid retention with hypertension. Cushingoid features. a low serum albumin. and suppressed inflammatory response. Patients are encouraged to eat a diet high in protein. vitamins. and minerals and low in sodium. Corticosteroids cause hypernatremia. not hyponatremia.

Explanation

Side effects of corticosteroids include weight gain. fluid retention with hypertension. Cushingoid features. a low serum albumin. and suppressed inflammatory response. Patients are encouraged to eat a diet high in protein. vitamins. and minerals and low in sodium. Corticosteroids cause hypernatremia. not hyponatremia.

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