NCLEX-RN Exam Pack Set 7 (75 Questions & Answers Updated 2024), Exams of Nursing

Download NCLEX-RN Exam Pack Set 7 (75 Questions & Answers Updated 2024) and more Exams Nursing in PDF only on Docsity! NCLEX-RN Exam Pack Set 7 (75 Questions & Answers Updated 2024) 1. Question The nurse is providing discharge teaching for the client with leukemia. The client should be told to avoid: o A. Using oil- or cream-based soaps o B. Flossing between the teeth o C. The intake of salt o D. Using an electric razor Correct Answer: B. Flossing between the teeth The client who is immune-suppressed and has bone marrow suppression should be taught not to floss his teeth because platelets are decreased. o Option A: Oil or cream-based soap is allowed for leukemia patients because these will prevent dry skin, which predisposes to skin injury. o Option C: A healthy amount of salt in the patient’s food is allowed. o Option D: The use of an electric razor is recommended because it reduces the risk of injury to the skin that can cause bleeding. • 2. Question The nurse is changing the ties of the client with a tracheostomy. The safest method of changing the tracheostomy ties is to: o A. Apply the new tie before removing the old one. o B. Have a helper present. P a g e 1 | 50 o C. Hold the tracheostomy with the nondominant hand while removing the old tie. o D. Ask the doctor to suture the tracheostomy in place. Correct Answer: A. Apply the new tie before removing the old one. Leaving the old ties in place while securing the clean ties prevents inadvertent dislodging of the tracheostomy tube. o Option B: Having a helper is good, but the helper might not prevent the client from coughing out the tracheotomy. o Option C: Hold the tracheostomy with the nondominant hand while removing the old tie is not the best way to prevent the client from coughing out the tracheotomy. o Option D: Asking the doctor to suture the tracheostomy in place is unnecessary. • 3. Question The nurse is monitoring a client following a lung resection. The hourly output from the chest tube was 300mL. The nurse should give priority to: o A. Turning the client to the left side oB. Milking the tube to ensure patency o C. Slowing the intravenous infusion o D. Notifying the physician Correct Answer: D. Notifying the physician The output of 300 mL is indicative of hemorrhage and should be reported immediately. o Option A: Turning the client to the left side does nothing to help the client. P a g e 2 | 50 Correct Answer: A. Tire easily The toddler with a ventricular septal defect will tire easily. The hole (defect) occurs in the wall (septum) that separates the heart’s lower chambers (ventricles) and allows blood to pass from the left to the right side of the heart. The oxygen-rich blood then gets pumped back to the lungs instead of out to the body, causing the heart to work harder. o Options B and C: He will not grow normally but will not need more calories. o Option D: He will be susceptible to bacterial infection, but he will be no more susceptible to viral infections than other children. • 7. Question The nurse is monitoring a client with a history of stillborn infants. The nurse is aware that a nonstress test can be ordered for this client to: o A. Determine lung maturity o B. Measure the fetal activity o C. Show the effect of contractions on fetal heart rate o D. Measure the wellbeing of the fetus Correct Answer: B. Measure the fetal activity A nonstress test determines periodic movement of the fetus. o Options A: Fetal lung maturity testing determines the maturity of the lungs. o Options C and D: Fetal heart rate monitoring measures the heart rate and rhythm of the baby (fetus) and its well being. • 8. Question The nurse is evaluating the client who was admitted 8 hours ago for induction of labor. The following graph is noted on the monitor. Which action should be taken first by the nurse? P a g e 5 | 50 o A. Instruct the client to push o B. Perform a vaginal exam o C. Turn off the Pitocin infusion o D. Place the client in a semi-Fowler’s position Correct Answer: C. Turn off the Pitocin infusion The monitor indicates variable decelerations caused by cord compression. If Pitocin is infusing, the nurse should turn off the Pitocin. o Option A: Instructing the client to push is because pushing could increase the decelerations and because the client is 8cm dilated, making answer A . o Options B and D: Performing a vaginal exam should be done after turning off the Pitocin, and placing the client in a semi-Fowler’s position is not appropriate for this situation. • 9. Question P a g e 6 | 50 The nurse notes the following on the ECG monitor. The nurse would evaluate the cardiac arrhythmia as: o A. Atrial flutter o B. A sinus rhythm o C. Ventricular tachycardia o D. Atrial fibrillation Correct Answer: C. Ventricular tachycardia The graph indicates ventricular tachycardia. o Options A, B, D: The answers in A, B, and D are not noted on the ECG strip. • 10. Question A client with clotting disorder has an order to continue lovenox (Enoxaparin) injections after discharge. The nurse should teach the client that lovenox injections should: o A. Be injected into the deltoid muscle o B. Be injected into the abdomen o C. Aspirate after the injection P a g e 7 | 50 oo C. Obtain a urinalysis monthly D. Wipe from back to front after voiding Correct Answer: B. Void every 3 hours Voiding every 3 hours prevents stagnant urine from collecting in the bladder, where bacteria can grow. o Options A and C: Douching is not recommended and obtaining a urinalysis monthly is not necessary. o Option D: The client should practice wiping from front to back after voiding and bowel movements. • 13. Question Which task should be assigned to the nursing assistant? o A. Placing the client in seclusion o B. Emptying the Foley catheter of the preeclamptic client o C. Feeding the client with dementia o D. Ambulating the client with a fractured hip Correct Answer: C. Feeding the client with dementia Of these clients, the one who should be assigned to the care of the nursing assistant is feeding the client with dementia. o Option A: Only a physician’s order can place the client in seclusion. o Option B: The nurse should empty the Foley catheter of the preeclamptic client because the client is unstable. o Option D: A nurse or physical therapist should ambulate the client with a fractured hip. • 14. Question o o The client has recently returned from having a thyroidectomy. The nurse should keep which of the following at the bedside? o A. A tracheostomy set B. A padded tongue blade C. An endotracheal tube o D. An airway Correct Answer: A. A tracheotomy set The client who has recently had a thyroidectomy is at risk for tracheal edema. o Option B: A padded tongue blade is used for seizures and not for the client with tracheal edema. o Options C and D: If the client experiences tracheal edema, the endotracheal tube or airway will not correct the problem. • 15. Question The physician has ordered a histoplasmosis test for the elderly client. The nurse is aware that histoplasmosis is transmitted to humans by: o A. Cats o B. Dogs o C. Turtles o D. Birds P a g e 11 | 50 o o Correct Answer: D. Birds Histoplasmosis is a fungus carried by birds. o Options A, B, C: Histoplasmosis is not transmitted to humans by cats, dogs, or turtles. • 16. Question What’s the first intervention for a patient experiencing chest pain and a p02 of 89%? o A. Administer morphine o B. Administer oxygen C. Administer sublingual nitroglycerin D. Obtain an electrocardiogram (ECC) Correct Answer: B. Administer oxygen Administering supplemental oxygen to the patient is the first priority. Administer oxygen to increase SpO2 to greater than 90% to help prevent further cardiac damage. o Options A and C: Sublingual nitroglycerin and morphine are commonly administered after oxygen. o Option D: Obtaining an ECG may occur after administering the oxygen to provide baseline data. • 17. Question Which of the following signs and symptoms usually signifies rapid expansion and impending rupture of an abdominal aortic aneurysm? o A. Abdominal pain o B. Absent pedal pulses o C. Chest pain o D. Lower back pain P a g e 12 | 50 o D. Administer sublingual nitroglycerin. Correct Answer: A. Have the patient sit down. The initial priority is to decrease oxygen consumption by sitting the patient down. o Options B, C, and D: Administer sublingual nitroglycerin as you simultaneously do the ECG. When the patient’s condition is stabilized, he can be returned to bed. • 20. Question Which of the following positions would best aid breathing for a patient with acute pulmonary edema? o A. Lying flat in bed o B. Left side-lying position o C. High Fowler’s position o D. Semi-Fowler’s position Correct Answer: C. High Fowler’s position High Fowler’s position facilitates breathing by reducing venous return. Lying flat and side-lying positions worsen breathing and increase the heart’s workload. o Option A: Lying flat in bed would make the patient feel like he is “drowning”. o Option C: Side-lying position worsens breathing and increases the heart’s workload. o Option D: Semi-Fowler’s may not be enough to improve the patient’s breathing. • 21. Question A pregnant woman arrives at the emergency department (ED) with abruptio placentae at 34 weeks’ gestation. She’s at risk for which of the following blood dyscrasias? o A. Heparin-associated thrombosis and thrombocytopenia (HATT) B. Idiopathic thrombocytopenic purpura (ITP) o C. Thrombocytopenia o D. Disseminated intravascular coagulation (DIC) Correct Answer: D. Disseminated intravascular coagulation (DIC) Abruptio placentae is a cause of DIC because it activates the clotting cascade after hemorrhage. o Option A: A patient with abruptio placentae wouldn’t get heparin and, as a result, wouldn’t be at risk for HATT. o Option B: ITP doesn’t have a definitive cause. o Option C: Thrombocytopenia results from decreased production of platelets. • 22. Question A 16-year-old patient involved in a motor vehicle accident arrives in the ED unconscious and severely hypotensive. He’s suspected to have several fractures of his pelvis and legs. Which of the following parenteral fluids is the best choice for his current condition? o A. Packed red blood cells o B. 0.9% sodium chloride solution o C. Lactated Ringer’s solution o D. Fresh frozen plasma Correct Answer: A. Packed red blood cells In a trauma situation, the first blood product given is unmatched (O negative) packed red P a g e 16 | 50 blood cells. o Options B and C: Lactated Ringer’s solution or 0.9% sodium chloride is used to increase volume and blood pressure, but too much of these crystalloids will dilute the blood and won’t improve oxygen-carrying capacity. o Option D: Fresh frozen plasma often is used to replace clotting factors. • 23. Question Corticosteroids are potent suppressors of the body’s inflammatory response. Which of the following conditions or actions do they suppress? o A. Cushing syndrome o B. Pain receptors o C. Immune response o D. Neural transmission Correct Answer: C. Immune response Corticosteroids suppress eosinophils, lymphocytes, and natural killer cells, inhibiting the natural inflammatory process in an infected or injured part of the body. This helps resolve inflammation, stabilizes lysosomal membranes, decreases capillary permeability, and depresses phagocytosis of tissues by white blood cells, thus blocking the release of more inflammatory materials. o Option A: Excessive corticosteroid therapy can lead to Cushing’s syndrome. o Option B: Analgesics suppress pain receptors. o Option D: Opioids and heroin may suppress neural transmission if taken in unregulated amounts. • 24. Question A patient infected with human immunodeficiency virus (HIV) begins zidovudine therapy. Which of the following statements best describes this drug’s action? P a g e 17 | 50 o A. Take a full medical history. o B. Give a bronchodilator by nebulizer. o C. Apply a cardiac monitor to the patient. o D. Provide emotional support for the patient. Correct Answer: B. Give a bronchodilator by nebulizer. The patient having an acute asthma attack needs more oxygen delivered to his lungs and body. Nebulized bronchodilators open airways and increase the amount of oxygen delivered. o Options A and D: Important but not a priority as of the moment; emotional support can help calm the patient but can be done after medical intervention. o Option C: The patient may not need cardiac monitoring because he’s only 19 years old unless he has a medical history of cardiac problems. • 27. Question A firefighter who was involved in extinguishing a house fire is being treated for smoke inhalation. He developed severe hypoxia 48 hours after the incident, requiring intubation and mechanical ventilation. Which of the following conditions has he most likely developed? o A. Atelectasis o B. Pneumonia o C. Bronchitis o D. Acute respiratory distress syndrome (ARDS) Correct Answer: D. Acute respiratory distress syndrome (ARDS). Severe hypoxia after smoke inhalation typically is related to ARDS. The other choices aren’t typically associated with smoke inhalation. o Option A: Atelectasis is a complete or partial collapse of the entire lung or area (lobe) of the lung. It occurs when the tiny air sacs (alveoli) within the lung become deflated or possibly filled with alveolar fluid. Atelectasis is one of the most common breathing (respiratory) complications after surgery. o Option B: Pneumonia is an infection that inflames the air sacs in one or both lungs. o Option C: P a g e 20 | 50 Bronchitis is an inflammation of the lining of your bronchial tubes, which carry air to and from your lungs. • 28. Question Which of the following measures best determines that a patient who had a pneumothorax no longer needs a chest tube? o A. You see a lot of drainage from the chest tube. o B. Arterial blood gas (ABG) levels are normal. o C. The chest X-ray continues to show the lung is 35% deflated. o D. The water-seal chamber doesn’t fluctuate when no suction is applied. Correct Answer: D. The water-seal chamber doesn’t fluctuate when no suction is applied. The chest tube isn’t removed until the patient’s lung has adequately re-expanded and is expected to stay that way. One indication of reexpansion is the cessation of fluctuation in the water-seal chamber when suction isn’t applied. o Option A: Drainage should be minimal before the chest tube is removed. o Option B: An ABG test isn’t necessary if clinical assessment criteria are met. o Option C: The chest X-ray should show that the lung is re-expanded. • 29. Question Which of the following nursing interventions should you use to prevent footdrop and contractures in a patient recovering from a subdural hematoma? o A. High-top sneakers P a g e 21 | 50 o B. Low-dose heparin therapy o C. Physical therapy consultation o D. Sequential compressive device Correct Answer: A. High-top sneakers High-top sneakers are used to prevent foot drop and contractures in patients with neurologic conditions. o Option B: Heparin therapy is not applicable to the treatment of foot drop and contractures. o Option C: A consult with physical therapy is important to prevent foot drop, but you can use high-top sneakers independently. o Option D: Sequential compression devices (SCDs) are inflatable sleeves that fit around the legs. The sleeves are attached to a pump that inflates and deflates the sleeves. The pumping action acts like muscles to help blood flow and prevent clots. SCDs are often used after surgery until the client can get up and walk. • 30. Question Which of the following signs of increased intracranial pressure (ICP) would appear first after head trauma? o A. Bradycardia o B. Large amounts of very dilute urine o C. Restlessness and confusion o D. Widened pulse pressure Correct Answer: C. Restlessness and confusion The earliest sign of increased ICP is a change in mental status. o Options A and D: Bradycardia and widened pulse pressure occur as later signs of increased ICP. P a g e 22 | 50 Correct Answer: B. Right side-lying, with the bed flat. Positioning the patient on his right side with the bed flat will splint the biopsy site and minimize bleeding. o Options A, C, D: The other positions won’t do this and may cause more bleeding at the site or internally. • 35. Question Which of the following potentially serious complications couldoccur with therapy for hypothyroidism? o A. Acute hemolytic reaction o B. Angina or cardiac arrhythmia o C. Retinopathy o D. Thrombocytopenia Correct Answer B. Angina or cardiac arrhythmia Precipitation of angina or cardiac arrhythmia is a potentially serious complication of hypothyroidism treatment. o Option A: Acute hemolytic reaction is a complication of blood transfusions. o Option C: Retinopathy typically is a complication of diabetes mellitus. o Option D: Thrombocytopenia doesn’t result from treating hypothyroidism. • 36. Question Adequate fluid replacement and vasopressin replacement are objectives of therapy for which of the following disease processes? Adequate fluid replacement and vasopressin replacement are objectives of therapy for which of the following disease processes? o A. Diabetes mellitus o B. Diabetes insipidus o C. Diabetic ketoacidosis P a g e 25 | 50 o D. Syndrome of inappropriate antidiuretic hormone secretion (SIADH) Correct Answer: B. Diabetes insipidus Maintaining adequate fluid and replacing vasopressin are the main objectives in treating diabetes insipidus. o Option A: Diabetes is a chronic condition associated with abnormally high levels of sugar (glucose) in the blood. Insulin produced by the pancreas lowers blood glucose. o Option C: Diabetic ketoacidosis is a result of severe insulin insufficiency. o Option D: An excess of antidiuretic hormone leads to SIADH, causing the patient to retain fluid. • 37. Question Patients with Type 1 diabetes mellitus may require which of the following changes to their daily routine during periods of infection? o A. No changes o B. Less insulin o C. More insulin o D. Oral diabetic agents Correct Answer: C. More insulin During periods of infection or illness, patients with Type 1 diabetes may need even more insulin to compensate for increased blood glucose levels. o Option A: Changes should be applied to the patient’s daily routine to avoid complications from infection. o Option B: Less insulin could lead to hyperglycemia. o Option D: Oral diabetic agents may not be enough to decrease the blood glucose. P a g e 26 | 50 • 38. Question On a follow-up visit after having a vaginal hysterectomy, a 32- year-old patient has a decreased hematocrit level. Which of the following complications does this suggest? o A. Hematoma o B. Hypovolemia o C. Infection o D. Pulmonary embolus (PE) Correct Answer: A. Hematoma A decreased hematocrit level is a sign of hematoma, a delayed complication of abdominal and vaginal hysterectomy. o Option B: Symptoms of hypovolemia include increased hematocrit and hemoglobin values. o Option C: Infection manifests with fever and high WBC count. o Option D: Symptoms of a PE include dyspnea, chest pain, cough, hemoptysis, restlessness, and signs of shock. • 39. Question A patient has partial-thickness burns to both legs and portions of his trunk. Which of the following I.V. fluids are given first? o A. Albumin o B. D5W o C. Lactated Ringer’s solution o D. 0.9% sodium chloride solution with 2 mEq of potassium per 100 ml P a g e 27 | 50 Correct Answer: C. Obesity Obesity is an important risk factor for coronary artery disease that can be modified by improved diet and weight loss. o Options A, B, and D: Family history of coronary artery disease, male gender, and advancing age increase risk but cannot be modified. • 43. Question Tissue plasminogen activator (t-PA) is considered for the treatment of a patient who arrives in the emergency department following the onset of symptoms of myocardial infarction. Which of the following is a contraindication for treatment with t-PA? o A. Worsening chest pain that began earlier in the evening o B. History of cerebral hemorrhage o C. History of prior myocardial infarction o D. Hypertension Correct Answer: B. History of cerebral hemorrhage A history of cerebral hemorrhage is a contraindication to tPA because it may increase the risk of bleeding. TPA acts by dissolving the clot blocking the coronary artery and works best when administered within 6 hours of onset of symptoms. o Option A: Chest pain is one of the symptoms of myocardial infarction. o Option C: Prior MI is not a contraindication to tPA. o Option D: Patients receiving tPA should be observed for changes in blood pressure, as tPA may cause hypotension. • 44. Question Following myocardial infarction, a hospitalized patient is encouraged to practice frequent leg exercises and ambulate in the hallway as directed by his physician. Which of the following choices reflects the purpose of exercise for this patient? P a g e 30 | 50 o A. Increases fitness and prevents future heart attacks o B. Prevents bedsores o C. Prevents DVT ( deep vein thrombosis) o D. Prevent constipations Correct Answer: C. Prevents DVT (deep vein thrombosis) Exercise is important for all hospitalized patients to prevent deep vein thrombosis. Muscular contraction promotes venous return and prevents hemostasis in the lower extremities. o Options A, B, and D: This exercise is not sufficiently vigorous to increase physical fitness, nor is it intended to prevent bedsores or constipation. • 45. Question A patient arrives in the emergency department with symptoms of myocardial infarction, progressing to cardiogenic shock. Which of the following symptoms should the nurse expect the patient to exhibit with cardiogenic shock? o A. Hypertension o B. Bradycardia o C. Bounding pulse o D. Confusion Correct Answer: D. Confusion Cardiogenic shock severely impairs the pumping function of the heart muscle, causing diminished blood flow to the organs of the body. This results in diminished brain function and confusion, as well as hypotension, tachycardia, and weak pulse. Cardiogenic shock is a serious complication of myocardial infarction with a high mortality rate. o Option A: The primary insult is a reduction in myocardial contractility resulting in diminished cardiac output, hypotension, systemic vasoconstriction, and cardiac ischemia. P a g e 31 | 50 o Option B: Tachycardia is a symptom as there is diminished oxygenated blood flow to peripheral tissues, which drives the heart to pump harder than normal. o Option C: A bounding pulse is not indicative of cardiogenic shock. • 46. Question 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? o A. Ask the patient to lie down on the exam table. o B. Draw blood for chemistry panel and arterial blood gas (ABG). o C. Send the patient for a chest x-ray. o D. Check blood pressure. Correct Answer: D. 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. o Option A: Lying flat on the exam table would likely worsen the dyspnea, and the patient may not tolerate it. o Option B: Blood draws for chemistry and ABG will be required, but not prior to the blood pressure assessment. o Option C: A chest X-ray may be ordered by the physician after priority nursing care. • 47. Question 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? o A. "Stop taking the nitroglycerin and see if the headaches improve." P a g e 32 | 50 o Option B: Mild anemia does not require that animal sources of iron be added to the diet. Many non-animal sources are available. o Option D: Coffee and tea increase gastrointestinal activity and inhibit the absorption of iron. • 50. Question A hospitalized patient is receiving packed red blood cells (PRBCs) for treatment of severe anemia. Which of the following is the most accurate statement? o A. Transfusion reaction is most likely immediately after the infusion is completed. o Error! Not a valid embedded object. B. PRBCs are best infused slowly through a 20g. IV catheter. o Error! Not a valid embedded object. C. PRBCs should be flushed with a 5% dextrose solution. o Error! Not a valid embedded object. D. A nurse should remain in the room during the first 15 minutes of infusion. Correct Answer: D. 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. o Option A: Transfusion reaction most likely occurs during the first 15 minutes, not after the infusion has been completed. o Option B: PRBCs should be infused through a 19g or larger IV catheter to avoid slow flow, which can cause clotting. o Option C: PRBCs must be flushed with 0.45% normal saline solution. Other intravenous solutions will hemolyze the cells. • 51. Question P a g e 35 | 50 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? o Error! Not a valid embedded object. A. An increase in neutrophil count o Error! Not a valid embedded object. B. An increase in hematocrit o Error! Not a valid embedded object. C. An increase in platelet count o Error! Not a valid embedded object. D. An increase in serum iron Correct Answer: B. An increase in hematocrit 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. o Option A: GCSFs, such as Neupogen (filgrastim, Amgen), Granix (tbo-filgrastim, Cephalon, Inc.), and Zarxio (filgrastim-sndz, Sandoz), stimulate and promote the maturation and activation of neutrophils. o Option C: Medications such as romiplostim (Nplate) and eltrombopag (Promacta) help the bone marrow produce more platelets. o Option D: Epoetin has no effect on neutrophils, platelets, or serum iron. • 52. Question 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. o Error! Not a valid embedded object. A. Weight loss o B. Increased clotting time o C. Hypertension o D. Headaches P a g e 36 | 50 o E. Polyphagia Correct Answer: B, C, and D 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. o Option A: Weight loss is not a manifestation of polycythemia vera. o Option E: Polyphagia or excessive hunger is a symptom of diabetes mellitus. • 53. Question A nurse is caring for a patient with a platelet count of 20,000/microliter. Which of the following is an importantintervention? o A. Observe for evidence of spontaneous bleeding. o B. Limit visitors to family only. o C. Give aspirin in case of headaches. o D. Impose immune precautions. Correct Answer: A. Observe for evidence of spontaneous bleeding. 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. o Options B and D: Thrombocytopenia does not compromise immunity, and there is no reason to limit visitors as long as any physical trauma is prevented. o Option C: Aspirin disables platelets and should never be used in the presence of thrombocytopenia. P a g e 37 | 50 Correct Answer: A. 3-10 years The peak incidence of ALL is at 4 years (range 3-10). o Option B: It is uncommon after the mid-teen years. o Option C: The peak incidence of chronic myelogenous leukemia (CML) is 45-55 years. o Option D: The peak incidence of acute myelogenous leukemia (AML) occurs at 60 years. Two-thirds of cases of chronic lymphocytic leukemia (CLL) occur after 60 years. • 58. Question A patient is admitted to the oncology unit for diagnosis of suspected Hodgkin’s disease. Which of the following symptoms is typical of Hodgkin’s disease? o A. Painful cervical lymph nodes o B. Night sweats and fatigue o C. Nausea and vomiting o D. Weight gain Correct Answer: B. Night sweats and fatigue Symptoms of Hodgkin’s disease include night sweats, fatigue, weakness, and tachycardia. o Option A: The disease is characterized by painless, enlarged cervical lymph nodes. o Option C: Nausea and vomiting are not typically symptoms of Hodgkin’s disease. o Option D: Weight loss occurs early in the disease. • 59. Question The Hodgkin’s disease patient described in the question above undergoes a lymph node biopsy for definitive diagnosis. If the diagnosis of Hodgkin’s disease were correct, which of the following cells would the pathologist expect to find? P a g e 40 | 50 o A. Lymphoblastic cells o B. Reed-Sternberg cells o C. Gaucher's cells o D. Rieder's cells Correct Answer: B. Reed-Sternberg cells A definitive diagnosis of Hodgkin’s disease is made if Reed- Sternberg cells are found on pathologic examination of the excised lymph node. o Option A: Lymphoblasts are immature cells found in the bone marrow of patients with acute lymphoblastic leukemia. o Option C: Gaucher’s cells are large storage cells found in patients with Gaucher’s disease. o Option D: Rieder’s cells are myeloblasts found in patients with acute myelogenous leukemia. • 60. Question A patient is about to undergo bone marrow aspiration and biopsy and expresses fear and anxiety about the procedure. Which of the following is the most effective nursing response? o A. Warn the patient to stay very still because the smallest movement will increase her pain. o B. Encourage the family to stay in the room for the procedure. o C. Stay with the patient and focus on slow, deep breathing for relaxation. o D. Delay the procedure to allow the patient to deal with her feelings. P a g e 41 | 50 Correct Answer: C. Stay with the patient and focus on slow, deep breathing for relaxation. Slow, deep breathing is the most effective method of reducing anxiety and stress. It reduces the level of carbon dioxide in the brain to increase calm and relaxation. o Option A: Warning the patient to remain still will likely increase her anxiety. o Option B: Encouraging family members to stay with the patient may make her worry about their anxiety as well as her own. o Option D: Delaying the procedure is unlikely to allay her fears. • 61. Question A 43-year-old African American male is admitted with sickle cell anemia. The nurse plans to assess circulation in the lower extremities every 2 hours. Which of the following outcome criteria would the nurse use? o A. Body temperature of 99°F or less o B. Toes moved in active range of motion o C. Sensation reported when soles of feet are touched o D. Capillary refill of < 3 seconds Correct Answer: D. Capillary refill of < 3 seconds 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. o Options A, B, and C: Body temperature, motion, and sensation would not give information regarding peripheral circulation. • 62. Question A 30-year-old male from Haiti is brought to the emergency department in sickle cell crisis. What is the best position for thisclient? P a g e 42 | 50 o Option A: Warm environment reduces pain and minimizes sickling, it would not be a priority. o Option B: Although hydration is important, it would not require a bolus. o Option D: Demerol is acidifying to the blood and increases sickling. • 66. Question The nurse is instructing a client with iron-deficiency anemia. Which of the following meal plans would the nurse expect the client to select? o A. Roast beef, gelatin salad, green beans, and peach pie o B. Chicken salad sandwich, coleslaw, French fries, ice cream o C. Egg salad on wheat bread, carrot sticks, lettuce salad, raisin pie o D. Pork chop, creamed potatoes, corn, and coconut cake Correct Answer: C. Egg salad on wheat bread, carrot sticks, lettuce salad, raisin pie Egg yolks, wheat bread, carrots, raisins, and green, leafy vegetables are all high in iron, which is an important mineral for this client. o Options A, B, and D: Roast beef, cabbage, and pork chops are also high in iron, but the side dishes accompanying these choices are not. • 67. Question Clients with sickle cell anemia are taught to avoid activities that cause hypoxia and hypoxemia. Which of the following activities would the nurse recommend? o A. A family vacation in the Rocky Mountains o B. Chaperoning the local boys club on a snow- skiing trip o C. Traveling by airplane for business trips o D. A bus trip to the Museum of Natural History P a g e 45 | 50 Correct Answer: D. A bus trip to the Museum of Natural History Taking a trip to the museum is the only answer that does not pose a threat. o Options A, B, and C: A family vacation in the Rocky Mountains at high altitudes, cold temperatures, and airplane travel can cause sickling episodes and should be avoided. • 68. Question The nurse is conducting an admission assessment of a client with vitamin B12 deficiency. Which of the following would the nurse include in the physical assessment? o A. Palpate the spleen o B. Take the blood pressure o C. Examine the feet for petechiae o D. Examine the tongue Correct Answer: D. Examine the tongue 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. o Options A, B, and C: Bleeding, splenomegaly, and blood pressure changes do not occur. • 69. Question An African American female comes to the outpatient clinic. The physician suspects vitamin B12 deficiency anemia. Because jaundice is often a clinical manifestation of this type of anemia, what body part would be the best indicator? o A. Conjunctiva of the eye o B. Soles of the feet o C. Roof of the mouth o D. Shins Correct Answer: C. Roof of the mouth The oral mucosa and hard palate (roof of the mouth) are the best indicators of jaundice in dark-skinned persons. o Option A: The conjunctiva can have normal deposits of fat, which give a P a g e 46 | 50 yellowish hue. o Option B: The soles of the feet can be yellow if they are calloused. o Option D: The shins would be an area of darker pigment. • 70. Question The nurse is conducting a physical assessment on a client with anemia. Which of the following clinical manifestations would be most indicative of the anemia? o A. BP 146/88 o B. Respirations 28 shallow o C. Weight gain of 10 pounds in 6 months o D. Pink complexion Correct Answer: B. Respirations 28 shallow When there are fewer red blood cells, there is less hemoglobin and less oxygen. Therefore, the client is often short of breath. o Options A, C, and D: The client with anemia is often pale in color, has weight loss, and may be hypotensive. • 71. Question 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? o A. "I will drink 500mL of fluid or less each day." o B. "I will wear support hose when I am up." o C. "I will use an electric razor for shaving." o D. "I will eat foods low in iron." Correct Answer: A. “I will drink 500mL of fluid or less each day.” The client with polycythemia vera is at risk for thrombus formation. Hydrating the client P a g e 47 | 50