NCLEX-RN Exam Pack Set 7 (75 Questions & Answers Updated 2022), Exams of Nursing

Download NCLEX-RN Exam Pack Set 7 (75 Questions & Answers Updated 2022) and more Exams Nursing in PDF only on Docsity! NCLEX-RN Exam Pack Set 7 (75 Questions & Answers Updated 2022) 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 | 48 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 o B. 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. o Options B and C: Milking the tube is done only with an order and will not help in this situation, and slowing the intravenous infusion is not an appropriate action. P a g e 2 | 48 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 | 48 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 The nurse notes the following on the ECG monitor. The nurse would evaluate the cardiac arrhythmia as: P a g e 6 | 48 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 o D. Clear the air from the syringe before injections Correct Answer: B. Be injected into the abdomen P a g e 7 | 48 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 Correct Answer: D. Birds P a g e 10 | 48 o o 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 Correct Answer: D. Lower back pain P a g e 11 | 48 o o Lower back pain results from the expansion of an aneurysm. The expansion applies pressure in the abdomen, and the pain is referred to the lower back. o Option A: Abdominal pain is the most common symptom resulting from impaired circulation. o Option B: Absent pedal pulses are a sign of no circulation and would occur after a ruptured aneurysm or in peripheral vascular disease. o Option C: Chest pain usually is associated with coronary artery or pulmonary disease. • 18. Question In which of the following types of cardiomyopathy does cardiac output remain normal? A. Obliterative B. Restrictive o C. Dilated o D. Hypertrophic Correct Answer: D. Hypertrophic Hypertrophic cardiomyopathy (HCM) is a condition in which there is a severe ventricular hypertrophy and poor diastolic filling. It is an autosomal dominant condition wherein the heart muscles asymmetrically increases in size and mass along the septum. The increase in the thickness of heart muscles reduces the size of the cavities of the ventricles causing them to take a longer time to relax after systole. Cardiac output isn’t affected by hypertrophic cardiomyopathy because the size of the ventricle remains relatively unchanged. o Options A and B: Restrictive cardiomyopathy (RCM) is wherein the walls of the heart are rigid causing a restrictive stretching and filling of blood properly. P a g e 12 | 48 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 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: P a g e 15 | 48 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? o A. It stimulates the immune system. o B. It destroys the outer wall of the virus and kills it. o C. It interferes with viral replication o D. It promotes excretion of viral antibodies. P a g e 16 | 48 Correct Answer: C. It interferes with viral replication. P a g e 17 | 48 • 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 o B. Low-dose heparin therapy o C. Physical therapy consultation o D. Sequential compressive device P a g e 20 | 48 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. o Option B: The patient may void a lot of very dilute urine if his posterior pituitary is damaged. • 31. Question P a g e 21 | 48 When giving intravenous (I.V.) phenytoin, which of the following methods should you use? o A. Use an in-line filter. o B. Withhold other anticonvulsants. o C. Mix the drug with saline solution only. o D. Flush the I.V. catheter with dextrose solution. Correct Answer: C. Mix the drug with saline solution only. Phenytoin is compatible only with saline solutions. o Options A and B: You needn’t withhold additional anticonvulsants or use an in-line filter. o Option D: Dextrose causes an insoluble precipitate to form. • 32. Question After surgical repair of a hip, which of the following positions is best for the patient’s legs and hips? o A. Abduction o B. Adduction o C. Prone o D. Subluxated Correct Answer: A. Abduction After surgical repair of the hip, keep the legs and hips abducted to stabilize the prosthesis in the acetabulum. o Option B: Adduction brings the limb or hand toward or across the midline of the body, or brings the fingers or toes together. o Option C: Prone position is a body position in which the person lies flat with the chest down and the back up. o Option D: A subluxation is a partial dislocation of a joint. It’s often the result of acute injury or repetitive motions, but it can also occur because of medical conditions where the ligaments are loose. P a g e 22 | 48 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. • 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. P a g e 25 | 48 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 Correct Answer: C. Lactated Ringer’s solution Lactated Ringer’s solution replaces lost sodium and corrects metabolic acidosis, both of which commonly occur following a burn. o Option A: Albumin is used as an adjunct therapy, not a primary fluid replacement. o Option B: Dextrose isn’t given to burn patients during the first 24 hours because it can cause pseudodiabetes. o Option D: The patient is hyperkalemic from the potassium shift from the intracellular space to the plasma, so potassium would be detrimental. • 40. Question Which of the following techniques is correct for obtaining a woundculture specimen from a surgical site? P a g e 26 | 48 o A. Thoroughly irrigate the wound before collecting the specimen. o B. Use a sterile swab and wipe the crusty area around the outside of the wound. o C. Gently roll a sterile swab from the center of the wound outward to collect drainage. o D. Use a sterile swab to collect drainage from the dressing. Correct Answer: C. Gently roll a sterile swab from the center of the wound outward to collect drainage. Rolling a swab from the center outward is the right way to obtain a culture specimen from a wound. o Option A: Irrigating the wound washes away drainage, debris, and many of the colonizing or infecting microorganisms. o Option B: The outside of the wound and the dressing may be colonized with microorganisms that haven’t affected the wound, so specimens from these sites could give inaccurate results. o Option D: The dressing is considered contaminated and should not be used for collection of specimens. • 41. Question A nurse is administering IV furosemide to a patient admitted with congestive heart failure. After the infusion, which of the following symptoms is not expected? o A. Increased urinary output o B. Decreased edema o C. Decreased pain o D. Decreased blood pressure Correct Answer: C. Decreased pain P a g e 27 | 48 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. 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 P a g e 30 | 48 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." o B. "Go to the emergency department to be checked because nitroglycerin can cause bleeding in the brain." o C. "Headaches are a frequent side effect of nitroglycerine because it causes vasodilation." o D. "The headaches are unlikely to be related to the nitroglycerin, so you should see your doctor for further investigation." Correct Answer: C. “Headaches are a frequent side effect of nitroglycerine because it causes vasodilation.” 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, nitroglycerin is effective at reducing myocardial oxygen consumption and increasing blood flow. o Option A: The patient should not stop the medication. o Option B: Nitroglycerine does not cause bleeding in the brain. o Option D: Headaches are one of the side effects of nitroglycerin. • 48. Question P a g e 31 | 48 A patient received surgery and chemotherapy for colon cancer, completing therapy three (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 would account for her symptoms? o A. The symptoms may be the result of anemia caused by chemotherapy. o B. The patient may be immunosuppressed. o C. The patient may be depressed. o D. The patient may be dehydrated. Correct Answer: A. The symptoms may be the result of anemia caused by chemotherapy. 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. o Option B: There is no evidence that the patient is immunosuppressed, and fatigue is not a typical symptom of immunosuppression. o Options C and D: The information given does not indicate that depression or dehydration is a cause of her symptoms. • 49. Question A clinic patient has a hemoglobin concentration of 10.8 g/dL and reports sticking to a strict vegetarian diet. Which of the following nutritional advice is appropriate? o A. The diet is providing adequate sources of iron and requires no changes. o B. The patient should add meat to her diet; a vegetarian diet is not advised. P a g e 32 | 48 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 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. P a g e 35 | 48 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. • 54. Question 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? Select all that apply. o A. Hypertension o B. Cushingoid features o C. Hyponatremia o D. Low serum albumin o E. Mood swings Correct Answer: A, B, D, and E. Side effects of corticosteroids include weight gain, fluid retention with hypertension, Cushingoid features, low serum albumin, suppressed inflammatory response, and mood swings. Patients are encouraged to eat a diet high in protein, vitamins, and minerals and low in sodium. o Option C: Corticosteroids cause hypernatremia and not hyponatremia. • 55. Question 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? P a g e 36 | 48 o A. Change the disposable mask immediately after use. o B. Change gloves immediately after use. o C. Minimize patient contact. o D. Minimize conversation with the patient. Correct Answer: B. Change gloves immediately after use. 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. o Option A: Changing the respiratory mask is desirable, but not nearly as urgent as changing gloves. o Options C and D: Minimizing contact and conversation are not necessary and may cause nursing staff to miss changes in the patient’s symptoms or condition. • 56. Question A patient is undergoing the induction stage of treatment for leukemia. The nurse teaches family members about infectious precautions. Which of the following statements by family members indicates that the family needs more education? o A. We will bring in books and magazines for entertainment. o B. We will bring in personal care items for comfort. o C. We will bring in fresh flowers to brighten the room. o D. We will bring in family pictures and get well cards. Correct Answer: C. We will bring in fresh flowers to brighten the room. P a g e 37 | 48 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. 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. P a g e 40 | 48 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? Correct Answer: D. Semi-Fowler’s with legs extended on the bed Placing the client in a semi-Fowler’s position provides the best oxygenation for this client. o Options A, B, and C: Flexion of the hips and knees, which includes the knee-chest position, impedes circulation and is not correct positioning for this client. • 63. Question A 25-year-old male is admitted in sickle cell crisis. Which of the following interventions would be of the highest priority for this client? o A. Taking hourly blood pressures with mechanical cuff o B. Encouraging fluid intake of at least 200mL per hour o C. Position in high Fowler’s with knee gatch raised o D. Administering Tylenol as ordered Correct Answer: B. Encouraging fluid intake of at least 200mL per hour It is important to keep the client in sickle cell crisis hydrated to prevent further sickling P a g e 41 | 48 o A. Side - lying with knees flexed o B. Knee -chest o C. High Fowler’s with knees flexed o D. Semi - Fowler’s with legs extended on the bed of the blood. o Option A: Taking hourly blood pressures with mechanical cuff is because a mechanical cuff places too much pressure on the arm. o Option C: Position in high Fowler’s with knee gatch raised is inappropriate because it impedes circulation. o Option D: Administering Tylenol is too mild an analgesic for the client in crisis. • 64. Question Which of the following foods would the nurse encourage the client in sickle cell crisis to eat? o A. Peaches o B. Cottage cheese o C. Popsicle o D. Lima beans Correct Answer: C. Popsicle Hydration is important in the client with sickle cell disease to prevent thrombus formation. Popsicles, gelatin, juice, and pudding have high fluid content. o Options A, B, D: These food items do not aid in hydration and are, therefore, . • 65. Question A newly admitted client has a sickle cell crisis. The nurse is planning care based on the assessment of the client. The client is complaining of severe pain in his feet and hands. The pulse oximetry is 92. Which of the following interventions would be implemented first? Assume that there are orders for each intervention. o A. Adjust the room temperature o B. Give a bolus of IV fluids o C. Start O2 P a g e 42 | 48 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 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." P a g e 45 | 48 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 with at least 3L of fluid per day is important in preventing clot formation, so the statement to drink less than 500mL is . o Option B: Wearing a support hose promotes venous return. o Option C: The electric razor prevents bleeding due to injury. o Option D: A diet low in iron is essential to preventing further red cell formation. • 72. Question 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? o A. The client collects stamps as a hobby. o B. The client recently lost his job as a postal worker. o C. The client had radiation for treatment of Hodgkin’s disease as a teenager. o D. The client’s brother had leukemia as a child. Correct Answer: C. The client had radiation for treatment of Hodgkin’s disease as a teenager. Radiation treatment for other types of cancer can result in leukemia. Some hobbies and occupations involving chemicals are linked to leukemia. o Option A: Collecting stamps does not predispose the client to acute leukemia. o Option B: Losing a job does not contribute to acute leukemia. o Option D: The incidence of leukemia is higher in twins than in siblings. P a g e 46 | 48 • 73. Question 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? o A. The abdomen o B. The thorax o C. The earlobes o D. The soles of the feet Correct Answer: D. 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. o Options A, B, and C: The skin in the abdomen, thorax, and earlobes might be too dark to make an assessment. • 74. Question A client with acute leukemia is admitted to the oncology unit. Which of the following would be most important for the nurse to inquire? o A. "Have you noticed a change in sleeping habits recently?" o B. "Have you had a respiratory infection in the last 6 months?" o C. "Have you lost weight recently?" o Error! Not a valid embedded object. D. "Have you noticed changes in your alertness?" Correct Answer: B. “Have you had a respiratory infection in the last 6 months?” The client with leukemia is at risk for infection and has often had recurrent respiratory infections during the previous 6 months. o Options A, C, and D: Insomnolence, weight loss, and a decrease in alertness also occur in leukemia, but P a g e 47 | 48