NCLEX Practice Exam 20 (10 Questions)

1. 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:

Bleeding precautions

Prevention of falls

Oxygen therapy

Conservation of energy

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 answer C is important. but platelets do not carry oxygen. Answers B and D are of lesser priority and are incorrect in this instance.

Explanation

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 answer C is important. but platelets do not carry oxygen. Answers B and D are of lesser priority and are incorrect in this instance.

2. A client has autoimmune thrombocytopenic purpura. To determine the client's response to treatment. the nurse would monitor:

Platelet count

White blood cell count

Potassium levels

Partial prothrombin time (PTT)

Clients with autoimmune thrombocytopenic purpura (ATP) have low platelet counts. making answer A the correct answer. White cell counts. potassium levels. and PTT are not affected in ATP; thus. answers B. C. and D are incorrect.

Explanation

Clients with autoimmune thrombocytopenic purpura (ATP) have low platelet counts. making answer A the correct answer. White cell counts. potassium levels. and PTT are not affected in ATP; thus. answers B. C. and D are incorrect.

3. 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?

The client collects stamps as a hobby.

The client recently lost his job as a postal worker.

The client had radiation for treatment of Hodgkin’s disease as a teenager.

The client’s brother had leukemia as a child.

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. answers A and B are incorrect. Answer D is incorrect because the incidence of leukemia is higher in twins than in siblings.

Explanation

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. answers A and B are incorrect. Answer D is incorrect because the incidence of leukemia is higher in twins than in siblings.

4. Which of the following would be the priority nursing diagnosis for the adult client with acute leukemia?

Oral mucous membrane. altered related to chemotherapy

Risk for injury related to thrombocytopenia

Fatigue related to the disease process

Interrupted family processes related to life-threatening illness of a family member

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 in answers A. C. and D. which are incorrect.

Explanation

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 in answers A. C. and D. which are incorrect.

5. 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?

“I will drink 500mL of fluid or less each day.”

“I will wear support hose when I am up.”

“I will use an electric razor for shaving.”

“I will eat foods low in iron.”

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. Answers B. C. and D 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.

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. Answers B. C. and D 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.

6. A client with acute leukemia is admitted to the oncology unit. Which of the following would be most important for the nurse to inquire?

“Have you noticed a change in sleeping habits recently?”

“Have you had a respiratory infection in the last 6 months?”

“Have you lost weight recently?”

“Have you noticed changes in your alertness?”

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; therefore. answers A. C. and D are incorrect.

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; therefore. answers A. C. and D are incorrect.

7. 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?

Sexual dysfunction related to radiation therapy

Anticipatory grieving related to terminal illness

Tissue integrity related to prolonged bed rest

Fatigue related to chemotherapy

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. Answers B. C. and D are incorrect because they are of lesser priority.

Explanation

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. Answers B. C. and D are incorrect because they are of lesser priority.

8. A client with a pituitary tumor has had a transsphenoidal hypophysectomy. Which of the following interventions would be appropriate for this client?

Place the client in Trendelenburg position for postural drainage

Encourage coughing and deep breathing every 2 hours

Elevate the head of the bed 30°

Encourage the Valsalva maneuver for bowel movements

Elevating the head of the bed 30° avoids pressure on the sella turcica and alleviates headaches. Answers A. B. and D are incorrect because Trendelenburg. Valsalva maneuver. and coughing all increase the intracranial pressure.

Explanation

Elevating the head of the bed 30° avoids pressure on the sella turcica and alleviates headaches. Answers A. B. and D are incorrect because Trendelenburg. Valsalva maneuver. and coughing all increase the intracranial pressure.

9. 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?

The abdomen

The thorax

The earlobes

The soles of the feet

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. Answers A. B. and C are incorrect because the skin might be too dark to make an assessment.

Explanation

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. Answers A. B. and C are incorrect because the skin might be too dark to make an assessment.

10. The client with a history of diabetes insipidus is admitted with polyuria. polydipsia. and mental confusion. The priority intervention for this client is:

Measure the urinary output

Check the vital signs

Encourage increased fluid intake

Weigh the client

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 answer A is incorrect. Encouraging fluid intake will not correct the problem. making answer C incorrect. Answer D is incorrect because weighing the client is not necessary at this time.

Explanation

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 answer A is incorrect. Encouraging fluid intake will not correct the problem. making answer C incorrect. Answer D is incorrect because weighing the client is not necessary at this time.