NCLEX-RN Exam Pack Set 7 (75 Questions & Answers Updated 2023/2024), Exams of Nursing

Download NCLEX-RN Exam Pack Set 7 (75 Questions & Answers Updated 2023/2024) and more Exams Nursing in PDF only on Docsity! Option A: Oil or cream-based soap is allowed for leukemia patients because these will prevent dry skin, which predisposes to skin injury. Option C: A healthy amount of salt in the patient’s food is allowed. Option D: The use of an electric razor is recommended because it reduces the risk of injury to the skin that can cause bleeding. 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. NCLEX-RN Exam Pack Set 7 (75 Questions & Answers Updated 2023/2024) 1. 1. Question The nurse is providing discharge teaching for the client withleukemia. 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 • 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. Option B: Having a helper is good, but the helper might not prevent the client from coughing out the tracheotomy. 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. Option D: Asking the doctor to suture the tracheostomy in place is unnecessary. 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. Option A: Turning the client to the left side does nothing to help the client. 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. Correct Answer: D. Notifying the physician The output of 300 mL is indicative of hemorrhage and should be reported immediately. o C. Hold the tracheostomy with the nondominant handwhile removing the old tie. o D. Ask the doctor to suture the tracheostomy in place. • 3. Question The nurse is monitoring a client following a lung resection. The hourly output from the chest tube was 300mL. The nurse shouldgive 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 Options A: Fetal lung maturity testing determines the maturity of the lungs. Options C and D: Fetal heart rate monitoring measures the heart rate and rhythm of the baby (fetus) and its well being. Correct Answer: B. Measure the fetal activity A nonstress test determines periodic movement of the fetus. 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 • 8. Question The nurse is evaluating the client who was admitted 8 hours agofor induction of labor. The following graph is noted on the monitor. Which action should be taken first by the nurse? Option A: Instructing the client to push is because pushing could increase the decelerations and because the client is 8cm dilated, making answer A . 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. 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 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 • 9. Question The nurse notes the following on the ECG monitor. The nursewould evaluate the cardiac arrhythmia as: 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. Correct Answer: B. Be injected into the abdomen o A. Atrial flutter o B. A sinus rhythm o C. Ventricular tachycardia o D. Atrial fibrillation • 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 Option B: A padded tongue blade is used for seizures and not for the client with tracheal edema. Options C and D: If the client experiences tracheal edema, the endotracheal tube or airway will not correct the problem. Correct Answer: A. A tracheotomy set The client who has recently had a thyroidectomy is at risk for tracheal edema. o Options A, B, C: Histoplasmosis is not transmitted to humans by cats, dogs, or turtles. Correct Answer: D. Birds Histoplasmosis is a fungus carried by birds. o B. A padded tongue blade o C. An endotracheal tube o D. An airway • 15. Question The physician has ordered a histoplasmosis test for the elderlyclient. The nurse is aware that histoplasmosis is transmitted to humans by: o A. Cats o B. Dogs o C. Turtles o D. Birds • 16. Question What’s the first intervention for a patient experiencing chestpain and a p02 of 89%? o A. Administer morphine o B. Administer oxygen Options A and C: Sublingual nitroglycerin and morphine are commonly administered after oxygen. Option D: Obtaining an ECG may occur after administering the oxygen to provide baseline data. 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. Option A: Abdominal pain is the most common symptom resulting from impaired circulation. Option B: Absent pedal pulses are a sign of no circulation and would occur after a ruptured aneurysm or in peripheral vascular disease. Option C: Chest pain usually is associated with coronary artery or pulmonary disease. Correct Answer: D. Lower back pain 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 C. Administer sublingual nitroglycerin o D. Obtain an electrocardiogram (ECC) • 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 • 18. Question In which of the following types of cardiomyopathy does cardiacoutput remain normal? o A. Obliterative o 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. Theincrease in the thickness of heart muscles reduces the size of thecavities 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. Restrictive and obliterative cardiomyopathy are the same. o Option C: Dilated cardiomyopathy (DCM) is a condition in which the left ventricle is enlarged and weakened causing a decrease in the ability to pump blood (decreased cardiac output). It is the most common type of cardiomyopathy and commonly leadsto progressive heart failure. The cause of DCM can be idiopathic or it can result from inflammatory processeslike myocarditis, or from cytotoxic agents like alcohol and certain neoplastic drugs. • 19. Question Which of the following interventions should be your first prioritywhen treating a patient experiencing chest pain while walking? o A. Have the patient sit down. o B. Get the patient back to bed. o C. Obtain an ECG. 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. Correct Answer: C. It interferes with viral replication. • 23. Question Corticosteroids are potent suppressors of the body’s inflammatory response. Which of the following conditions oractions do they suppress? o A. Cushing syndrome o B. Pain receptors o C. Immune response o D. Neural transmission • 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. Option A: Holding in his coughs will only increase his pain. Option B: Placing the head of the bed flat may increase the frequency of his cough and his work of breathing. Option C: Increasing fluid intake will help thin the secretions, making it easier for him to clear them. Correct Answer: D. “Splint your chest wall with a pillow for comfort.” Showing this patient how to splint his chest wall will help decrease discomfort when coughing. Zidovudine inhibits DNA synthesis in HIV, thus interfering with viral replication. The drug doesn’t destroy the viral wall, stimulate the immune system, or promote HIV antibody excretion. o Options A, B, D: These options are not functions of Zidovudine.• 25. Question A 20-year-old patient is being treated for pneumonia. He has a persistent cough and complains of severe pain on coughing. Whatcould you tell him to help him reduce his discomfort? o A. "Hold your cough as much as possible." o B. "Place the head of your bed flat to help with coughing." o C. "Restrict fluids to help decrease the amount of sputum." o D. "Splint your chest wall with a pillow for comfort." • 26. Question A 19-year-old patient comes to the ED with acute asthma. His respiratory rate is 44 breaths/minute, and he appears to be in acute respiratory distress. Which of the following actions shouldyou take first? o A. Take a full medical history. 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. 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. 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. 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 B. Give a bronchodilator by nebulizer. o C. Apply a cardiac monitor to the patient. o D. Provide emotional support for the patient. • 27. Question A firefighter who was involved in extinguishing a house fire is being treated for smoke inhalation. He developed severe hypoxia48 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) Options A and B: You needn’t withhold additional anticonvulsants or use an in-line filter. Option D: Dextrose causes an insoluble precipitate to form. Correct Answer: C. Mix the drug with saline solution only. Phenytoin is compatible only with saline solutions. Option B: Adduction brings the limb or hand toward or across the midline of the body, or brings the fingers or toes together. Option C: Prone position is a body position in which the person lies flat with the chest down and the back up. Correct Answer: A. Abduction After surgical repair of the hip, keep the legs and hips abducted to stabilize the prosthesis in the acetabulum. • 31. Question 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. • 32. Question After surgical repair of a hip, which of the following positions isbest for the patient’s legs and hips? o A. Abduction o B. Adduction o C. Prone o D. Subluxated Correct Answer: B. Fluid and electrolyte balance Acute pancreatitis is commonly associated with fluid isolation and accumulation in the bowel secondary to ileus or peripancreatic edema. Fluid and electrolyte loss from vomiting is a major concern. Therefore, your priority is to manage hypovolemia and restore electrolyte balance. o Options A and D: Pain control and nutrition also are important, but not priority. o Option C: Patients are at risk for hyperglycemia, not hypoglycemia. 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. • 33. Question Which of the following factors should be the primary focus ofnursing management in a patient with acute pancreatitis? o A. Nutrition management o B. Fluid and electrolyte balance o C. Management of hypoglycemia o D. Pain control • 34. Question After a liver biopsy, place the patient in which of the followingpositions? o A. Left side-lying, with the bed flat o B. Right side-lying, with the bed flat o C. Left side-lying, with the bed in semi-Fowler’s position o D. Right side-lying, with the bed in semi- Fowler’s position Option A: Acute hemolytic reaction is a complication of blood transfusions. Option C: Retinopathy typically is a complication of diabetes mellitus. Option D: Thrombocytopenia doesn’t result from treating hypothyroidism. Correct Answer B. Angina or cardiac arrhythmia Precipitation of angina or cardiac arrhythmia is a potentially serious complication of hypothyroidism treatment. 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 • 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 followingdisease processes? o A. Diabetes mellitus o B. Diabetes insipidus o C. Diabetic ketoacidosis Option A: Irrigating the wound washes away drainage, debris, and many of the colonizing or infecting microorganisms. 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. Option D: The dressing is considered contaminated and should not be used for collection of specimens. 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: 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? o A. Thoroughly irrigate the wound before collecting the specimen. o B. Use a sterile swab and wipe the crusty area aroundthe outside of the wound. o C. Gently roll a sterile swab from the center of thewound outward to collect drainage. o D. Use a sterile swab to collect drainage from the dressing. Option A: Furosemide acts on the kidneys to increase urinary output. Option B: Fluid may move from the periphery, decreasing edema. Option D: Fluid load is reduced, lowering blood pressure. Correct Answer: C. Decreased pain Furosemide, a loop diuretic, does not alter pain. o Options A, B, and D: Family history of coronary artery disease, male gender, and advancing age increase risk but cannot be modified. Correct Answer: C. Obesity Obesity is an important risk factor for coronary artery disease that can be modified by improved diet and weight loss. • 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 • 42. Question There are a number of risk factors associated with coronary artery disease. Which of the following is a modifiable risk factor? o A. Gender o B. Age o C. Obesity o D. Heredity Option A: Chest pain is one of the symptoms of myocardial infarction. Option C: Prior MI is not a contraindication to tPA. Option D: Patients receiving tPA should be observed for changes in blood pressure, as tPA may cause hypotension. 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. • 43. Question Tissue plasminogen activator (t-PA) is considered for the treatment of a patient who arrives in the emergency departmentfollowing 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 • 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 followingchoices reflects the purpose of exercise for this patient? 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. “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 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." • 48. Question 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 herweekly bridge games. Which of the following explanations wouldaccount 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. Option B: There is no evidence that the patient is immunosuppressed, and fatigue is not a typical symptom of immunosuppression. Options C and D: The information given does not indicate that depression or dehydration is a cause of her symptoms. 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. Option A: In addition, dark green leafy vegetables, such as spinach and kale, and legumes are high in iron. Option B: Mild anemia does not require that animal sources of iron be added to the diet. Many non-animal sources are available. Option D: Coffee and tea increase gastrointestinal activity and inhibit the absorption of iron. Correct Answer: C. The patient should use iron cookware to prepare foods, such as dark green, leafy vegetables, and legumes, which are high in iron. Normal hemoglobin values range from 11.5-15.0. This vegetarian patient is mildly anemic. When food is prepared in iron cookware its iron content is increased. • 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 vegetariandiet is not advised. o C. The patient should use iron cookware to prepare foods, such as dark-green, leafy vegetables,and legumes, which are high in iron. o D. A cup of coffee or tea should be added to every meal Option A: Transfusion reaction most likely occurs during the first 15 minutes, not after the infusion has been completed. Option B: PRBCs should be infused through a 19g or larger IV catheter to avoid slow flow, which can cause clotting. Option C: PRBCs must be flushed with 0.45% normal saline solution. Other intravenous solutions will hemolyze the cells. 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. • 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 afterthe infusion is completed. o Error! Not a valid embedded object. B. PRBCs are bestinfused slowly through a 20g. IV catheter. o Error! Not a valid embedded object. C. PRBCs should beflushed 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. • 51. Question A patient who has received chemotherapy for cancer treatment isgiven an injection of Epoetin. Which of the following should reflectthe 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 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. Option A: Changing the respiratory mask is desirable, but not nearly as urgent as changing gloves. 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. 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 C. Hyponatremia o D. Low serum albumin o E. Mood swings • 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 aneutropenic patient? 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: C. We will bring in fresh flowers to brighten the room. During induction chemotherapy, the leukemia patient is severely immunocompromised and at risk of serious infection. Fresh flowers, fruit, and plants can carry microbes and should be avoided. o Options A, B, and D: Books, pictures, and other personal items can be cleaned with antimicrobials before being brought into the room to minimize the risk of contamination. Correct Answer: A. 3-10 years • 56. Question A patient is undergoing the induction stage of treatment for leukemia. The nurse teaches family members about infectiousprecautions. 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 theroom. o D. We will bring in family pictures and get well cards. • 57. Question A nurse is caring for a patient with acute lymphoblastic leukemia(ALL). Which of the following is the most likely age range of the patient? o A. 3-10 years o B. 25-35 years o C. 45-55 years o D. over 60 years Option A: The disease is characterized by painless, enlarged cervical lymph nodes. Option C: Nausea and vomiting are not typically symptoms of Hodgkin’s disease. Option D: Weight loss occurs early in the disease. Correct Answer: B. Night sweats and fatigue Symptoms of Hodgkin’s disease include night sweats, fatigue, weakness, and tachycardia. 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 istypical 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 • 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? o A. Lymphoblastic cells o B. Reed-Sternberg cells 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. 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. Option A: Taking hourly blood pressures with mechanical cuff is because a mechanical cuff places too much pressure on the arm. Option C: Position in high Fowler’s with knee gatch raised is inappropriate because it impedes circulation. Option D: Administering Tylenol is too mild an analgesic for the client in crisis. 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 of the blood. • 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 perhour o C. Position in high Fowler’s with knee gatch raised o D. Administering Tylenol as ordered • 64. Question Which of the following foods would the nurse encourage theclient in sickle cell crisis to eat? o A. Peaches o B. Cottage cheese 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, . Option A: Warm environment reduces pain and minimizes sickling, it would not be a priority. Option B: Although hydration is important, it would not require a bolus. Option D: Demerol is acidifying to the blood and increases sickling. Correct Answer: C. Start O2 The most prominent clinical manifestation of sickle cell crisis is pain. However, the pulse oximetry indicates that oxygen levels are low; thus, oxygenation takes precedence over pain relief. o C. Popsicle o D. Lima beans • 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 iscomplaining 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 o D. Administer meperidine (Demerol) 75 mg IV push 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. • 66. Question The nurse is instructing a client with iron-deficiency anemia. Which of the following meal plans would the nurse expect theclient to select? o A. Roast beef, gelatin salad, green beans, and peach pie o B. Chicken salad sandwich, coleslaw, French fries, icecream o C. Egg salad on wheat bread, carrot sticks, lettucesalad, 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 • 67. Question Clients with sickle cell anemia are taught to avoid activities thatcause 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 Option B: Wearing a support hose promotes venous return. Option C: The electric razor prevents bleeding due to injury. Option D: A diet low in iron is essential to preventing further red cell formation. 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 . Option A: Collecting stamps does not predispose the client to acute leukemia. Option B: Losing a job does not contribute to acute leukemia. Option D: The incidence of leukemia is higher in twins than in siblings. 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. • 72. Question A 33-year-old male is being evaluated for possible acute leukemia. Which of the following would the nurse inquire about asa 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: 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. 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. • 73. Question An African American client is admitted with acute leukemia. Thenurse 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 • 74. Question A client with acute leukemia is admitted to the oncology unit. Which of the following would be most important for the nurse toinquire? o A. "Have you noticed a change in sleeping habits recently?" o B. "Have you had a respiratory infection in thelast 6 months?" o C. "Have you lost weight recently?" o Error! Not a valid embedded object. D. "Have you noticed changes in your alertness?" Option A: Alterations in the oral mucous membrane may occur with chemotherapy but it is not a priority. Option C: Fatigue is common among patients receiving chemotherapy but not a priority. Option D: Interrupted family processes can also be a diagnosis but not a priority. Correct Answer: B. Risk for injury related to thrombocytopenia The client with acute leukemia has bleeding tendencies due to decreased platelet counts, and any injury would exacerbate the problem. o Options A, C, and D: Insomnolence, weight loss, and a decrease in alertness also occur in leukemia, but bleeding tendencies and infections are the primary clinical manifestations. • 75. Question Which of the following would be the priority nursing diagnosisfor the adult client with acute leukemia? o Error! Not a valid embedded object. A. Oral mucous membrane, altered related to chemotherapy o Error! Not a valid embedded object. B. Risk for injuryrelated to thrombocytopenia o C. Fatigue related to the disease process o D. Interrupted family processes related to life- threatening illness of a family member