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NCLEX- RN Practice Exam 7 (PM)*
Text Mode – Text version of the exam
1. 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?
- Body temperature of 99°F or less
- Toes moved in active range of motion
- Sensation reported when soles of feet are touched
- Capillary refill of < 3 seconds
2. A 30-year-old male from Haiti is brought to the emergency department in sickle cell crisis. What is the best position for this client?
- Side-lying with knees flexed
- High Fowler’s with knees flexed
- Semi-Fowler’s with legs extended on the bed
3. A 25-year-old male is admitted in sickle cell crisis. Which of the following interventions would be of highest priority for this client?
- Taking hourly blood pressures with mechanical cuff
- Encouraging fluid intake of at least 200mL per hour
- Position in high Fowler’s with knee gatch raised
- Administering Tylenol as ordered
4. Which of the following foods would the nurse encourage the client in sickle cell crisis to eat?
- Cottage cheese
- Lima beans
5. A newly admitted client has sickle cell crisis. The nurse is planning care based on 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.
- Adjust the room temperature
- Give a bolus of IV fluids
- Start O2
- Administer meperidine (Demerol) 75mg IV push
6. The nurse is instructing a client with iron-deficiency anemia. Which of the following meal plans would the nurse expect the client to select?
- Roast beef, gelatin salad, green beans, and peach pie
- Chicken salad sandwich, coleslaw, French fries, ice cream
- Egg salad on wheat bread, carrot sticks, lettuce salad, raisin pie
- Pork chop, creamed potatoes, corn, and coconut cake
7. Clients with sickle cell anemia are taught to avoid activities that cause hypoxia and hypoxemia. Which of the following activities would the nurse recommend?
- A family vacation in the Rocky Mountains
- Chaperoning the local boys club on a snow-skiing trip
- Traveling by airplane for business trips
- A bus trip to the Museum of Natural History
8. 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?
- Palpate the spleen
- Take the blood pressure
- Examine the feet for petechiae
- Examine the tongue
9. 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?
- Conjunctiva of the eye
- Soles of the feet
- Roof of the mouth
10. 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?
- BP 146/88
- Respirations 28 shallow
- Weight gain of 10 pounds in 6 months
- Pink complexion
11. The nurse is teaching the client with polycythemia vera about prevention of complications of the disease. Which of the following statements by the client indicates a need for further teaching?
- “I will drink 500mL of fluid or less each day.”
- “I will wear support hose when I am up.”
- “I will use an electric razor for shaving.”
- “I will eat foods low in iron.”
12. A 33-year-old male is being evaluated for possible acute leukemia. Which of the following would the nurse inquire about as a part of the assessment?
- The client collects stamps as a hobby.
- The client recently lost his job as a postal worker.
- The client had radiation for treatment of Hodgkin’s disease as a teenager.
- The client’s brother had leukemia as a child.
13. An African American client is admitted with acute leukemia. The nurse is assessing for signs and symptoms of bleeding. Where is the best site for examining for the presence of petechiae?
- The abdomen
- The thorax
- The earlobes
- The soles of the feet
14. A client with acute leukemia is admitted to the oncology unit. Which of the following would be most important for the nurse to inquire?
- “Have you noticed a change in sleeping habits recently?”
- “Have you had a respiratory infection in the last 6 months?”
- “Have you lost weight recently?”
- “Have you noticed changes in your alertness?”
15. Which of the following would be the priority nursing diagnosis for the adult client with acute leukemia?
- Oral mucous membrane, altered related to chemotherapy
- Risk for injury related to thrombocytopenia
- Fatigue related to the disease process
- Interrupted family processes related to life-threatening illness of a family member
16. A 21-year-old male with Hodgkin’s lymphoma is a senior at the local university. He is engaged to be married and is to begin a new job upon graduation. Which of the following diagnoses would be a priority for this client?
- Sexual dysfunction related to radiation therapy
- Anticipatory grieving related to terminal illness
- Tissue integrity related to prolonged bed rest
- Fatigue related to chemotherapy
17. A client has autoimmune thrombocytopenic purpura. To determine the client’s response to treatment, the nurse would monitor:
- Platelet count
- White blood cell count
- Potassium levels
- Partial prothrombin time (PTT)
18. The home health nurse is visiting a client with autoimmune thrombocytopenic purpura (ATP). The client’s platelet count currently is 80, It will be most important to teach the client and family about:
- Bleeding precautions
- Prevention of falls
- Oxygen therapy
- Conservation of energy
19. A client with a pituitary tumor has had a transphenoidal hyposphectomy. Which of the following interventions would be appropriate for this client?
- Place the client in Trendelenburg position for postural drainage
- Encourage coughing and deep breathing every 2 hours
- Elevate the head of the bed 30°
- Encourage the Valsalva maneuver for bowel movements
20. The client with a history of diabetes insipidus is admitted with polyuria, polydipsia, and mental confusion. The priority intervention for this client is:
- Measure the urinary output
- Check the vital signs
- Encourage increased fluid intake
- Weigh the client
21. A client with hemophilia has a nosebleed. Which nursing action is most appropriate to control the bleeding?
- Place the client in a sitting position with the head hyperextended
- Pack the nares tightly with gauze to apply pressure to the source of bleeding
- Pinch the soft lower part of the nose for a minimum of 5 minutes
- Apply ice packs to the forehead and back of the neck
22. A client has had a unilateral adrenalectomy to remove a tumor. To prevent complications, the most important measurement in the immediate post-operative period for the nurse to take is:
- Blood pressure
- Specific gravity
23. A client with Addison’s disease has been admitted with a history of nausea and vomiting for the past 3 days. The client is receiving IV glucocorticoids (Solu-Medrol). Which of the following interventions would the nurse implement?
- Glucometer readings as ordered
- Intake/output measurements
- Sodium and potassium levels monitored
- Daily weights
24. A client had a total thyroidectomy yesterday. The client is complaining of tingling around the mouth and in the fingers and toes. What would the nurses’ next action be?
- Obtain a crash cart
- Check the calcium level
- Assess the dressing for drainage
- Assess the blood pressure for hypertension
25. A 32-year-old mother of three is brought to the clinic. Her pulse is 52, there is a weight gain of 30 pounds in 4 months, and the client is wearing two sweaters. The client is diagnosed with hypothyroidism. Which of the following nursing diagnoses is of highest priority?
- Impaired physical mobility related to decreased endurance
- Hypothermia r/t decreased metabolic rate
- Disturbed thought processes r/t interstitial edema
- Decreased cardiac output r/t bradycardia
26. A community health nurse is conducting a teaching session about terrorism with members of the community and discussing information regarding anthrax. The nurse tells those attending that anthrax can be transmitted via which route(s)? Select all that apply.
- Direct contact with an infected individual
- Sexual contact with an infected individual
27. The emergency room nurse is providing discharge teaching to the parents of a 2-year-old child who sustained burns from a hot cup of coffee that had been left on the kitchen counter. The nurse evaluates that the parents have correctly understood the teaching when they state which of the following?
- “We will be sure to not leave hot liquids unattended.”
- “I guess my child needs to understand what the word ‘hot’ means.”
- “We will be sure that our child stays in his room when we work in the kitchen.”
- “We will install a safety gate as soon as we get home so that our child can’t get into the kitchen.”
28. A licensed practical nurse is attending an agency orientation meeting about the nursing model of practice implemented in the facility. The nurse is told that the nursing model is a team nursing approach. The nurse understands that which of the following is a characteristic of this type of nursing model of practice?
- A task approach method is used to provide care to clients.
- Managed care concepts and tools are used when providing client care.
- Nursing staff are led by a nurse when providing care to a group of clients.
- A single registered nurse is responsible for providing nursing care to a group of clients.
29. A licensed practical nurse is planning the client assignments for the day. Which of the following is the most appropriate assignment for the nursing assistant?
- A client who requires wound irrigation
- A client who requires frequent ambulation
- A client who is receiving continuous tube feedings
- A client who requires frequent vital signs after a cardiac catheterization
30. A male client who has heart failure receives an additional dose of bumetanide as prescribed 4 hours after the daily dose. The nurse assesses him 15 minutes after administering the medication and reminds him to save all urine in the bathroom. Thirty minutes later the nurse finds the client on the floor, unresponsive, and bleeding from a laceration. Determine the issues that support the client’s malpractice claim. Select all that apply.
- Failure to replace body fluids
- Increased risk of hypotension
- Failure to teach the client adequately
- Increased need to protect the client
- Excessive bumetanide administration
- Lack of follow-up nursing actions
Answers and Rationales
- Answer D . 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. Body temperature, motion, and sensation would not give information regarding peripheral circulation; therefore, answers A, B, and C are incorrect.
- Answer D. Placing the client in semi-Fowler’s position provides the best oxygenation for this client. Flexion of the hips and knees, which includes the knee-chest position, impedes circulation and is not correct positioning for this client. Therefore, answers A, B, and C are incorrect.
- Answer B . It is important to keep the client in sickle cell crisis hydrated to prevent further sickling of the blood. Answer A is incorrect because a mechanical cuff places too much pressure on the arm. Answer C is incorrect because raising the knee gatch impedes circulation. Answer D is incorrect because Tylenol is too mild an analgesic for the client in crisis.
- Answer C . Hydration is important in the client with sickle cell disease to prevent thrombus formation. Popsicles, gelatin, juice, and pudding have high fluid content. The foods in answers A, B, and D do not aid in hydration and are, therefore, incorrect.
- Answer C . 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. Answer A is incorrect because although a warm environment reduces pain and minimizes sickling, it would not be a priority. Answer B is incorrect because although hydration is important, it would not require a bolus. Answer D is incorrect because Demerol is acidifying to the blood and increases sickling.
- Answer C. Egg yolks, wheat bread, carrots, raisins, and green, leafy vegetables are all high in iron, which is an important mineral for this client. Roast beef, cabbage, and pork chops are also high in iron, but the side dishes accompanying these choices are not; therefore, answers A, B, and D are incorrect.
- Answer D . Taking a trip to the museum is the only answer that does not pose a threat. A family vacation in the Rocky Mountains at high altitudes, cold temperatures, and airplane travel can cause sickling episodes and should be avoided; therefore, answers A, B, and C are incorrect.
- Answer D. 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. Bleeding, splenomegaly, and blood pressure changes do not occur, making answers A, B, and C incorrect.
- Answer C. The oral mucosa and hard palate (roof of the mouth) are the best indicators of jaundice in dark-skinned persons. The conjunctiva can have normal deposits of fat, which give a yellowish hue; thus, answer A is incorrect. The soles of the feet can be yellow if they are calloused, making answer B incorrect; the shins would be an area of darker pigment, so answer D is incorrect.
- Answer B . When there are fewer red blood cells, there is less hemoglobin and less oxygen. Therefore, the client is often short of breath, as indicated in answer B. The client with anemia is often pale in color, has weight loss, and may be hypotensive. Answers A, C, and D are within normal and, therefore, are incorrect.
- Answer A. The client with polycythemia vera is at risk for thrombus formation. Hydrating the client with at least 3L of fluid per day is important in preventing clot formation, so the statement to drink less than 500mL is incorrect. Answers B, C, and D are incorrect because they all contribute to the prevention of complications. Support hose promotes venous return, the electric razor prevents bleeding due to injury, and a diet low in iron is essential to preventing further red cell formation.
- Answer C. Radiation treatment for other types of cancer can result in leukemia. Some hobbies and occupations involving chemicals are linked to leukemia, but not the ones in these answers; therefore, answers A and B are incorrect. Answer D is incorrect because the incidence of leukemia is higher in twins than in siblings.
- Answer D . 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 petichiae. Answers A, B, and C are incorrect because the skin might be too dark to make an assessment.
- Answer B . The client with leukemia is at risk for infection and has often had recurrent respiratory infections during the previous 6 months. Insomnolence, weight loss, and a decrease in alertness also occur in leukemia, but bleeding tendencies and infections are the primary clinical manifestations; therefore, answers A, C, and D are incorrect.
- Answer B. The client with acute leukemia has bleeding tendencies due to decreased platelet counts, and any injury would exacerbate the problem. The client would require close monitoring for hemorrhage, which is of higher priority than the diagnoses in answers A, C, and D, which are incorrect.
- Answer A. Radiation therapy often causes sterility in male clients and would be of primary importance to this client. The psychosocial needs of the client are important to address in light of the age and life choices. Hodgkin’s disease, however, has a good prognosis when diagnosed early. Answers B, C, and D are incorrect because they are of lesser priority.
- Answer A . Clients with autoimmune thrombocytopenic purpura (ATP) have low platelet counts, making answer A the correct answer. White cell counts, potassium levels, and PTT are not affected in ATP; thus, answers B, C, and D are incorrect.
- Answer A. The normal platelet count is 120,000–400, Bleeding occurs in clients with low platelets. The priority is to prevent and minimize bleeding. Oxygenation in answer C is important, but platelets do not carry oxygen. Answers B and D are of lesser priority and are incorrect in this instance.
- Answer C. Elevating the head of the bed 30° avoids pressure on the sella turcica and alleviates headaches. Answers A, B, and D are incorrect because Trendelenburg, Valsalva maneuver, and coughing all increase the intracranial pressure.
- Answer B . The large amount of fluid loss can cause fluid and electrolyte imbalance that should be corrected. The loss of electrolytes would be reflected in the vital signs. Measuring the urinary output is important, but the stem already says that the client has polyuria, so answer A is incorrect. Encouraging fluid intake will not correct the problem, making answer C incorrect. Answer D is incorrect because weighing the client is not necessary at this time.
- Answer C . The client should be positioned upright and leaning forward, to prevent aspiration of blood. Answers A, B, and D are incorrect because direct pressure to the nose stops the bleeding, and ice packs should be applied directly to the nose as well. If a pack is necessary, the nares are loosely packed.
- Answer A . Blood pressure is the best indicator of cardiovascular collapse in the client who has had an adrenal gland removed. The remaining gland might have been suppressed due to the tumor activity. Temperature would be an indicator of infection, decreased output would be a clinical manifestation but would take longer to occur than blood pressure changes, and specific gravity changes occur with other disorders; therefore, answers B, C, and D are incorrect.
- Answer A. IV glucocorticoids raise the glucose levels and often require coverage with insulin. Answer B is not necessary at this time, sodium and potassium levels would be monitored when the client is receiving mineral corticoids, and daily weights is unnecessary; therefore, answers B, C, and D are incorrect.
- Answer B . The parathyroid glands are responsible for calcium production and can be damaged during a thyroidectomy. The tingling is due to low calcium levels. The crash cart would be needed in respiratory distress but would not be the next action to take; thus, answer A is incorrect. Hypertension occurs in thyroid storm and the drainage would occur in hemorrhage, so answers C and D are incorrect.
- Answer D . The decrease in pulse can affect the cardiac output and lead to shock, which would take precedence over the other choices; therefore, answers A, B, and C are incorrect.
- Answers A, C, and D. Anthrax is caused by Bacillus anthracis, and it can be contracted through the digestive system, abrasions in the skin, or inhalation. It cannot be spread from person to person.
- Answer A. Toddlers, with their increased mobility and developing motor skills, can reach hot water, open fires, or hot objects placed on counters and stoves above their eye level. Parents should be encouraged to remain in the kitchen when preparing a meal and reminded to use the back burners on the stove. Pot handles should be turned inward and toward the middle of the stove. Hot liquids should never be left unattended, and the toddler should always be supervised. All other answer choices do not reflect an adequate understanding of the principles of safety.
- Answer C. In team nursing, nursing personnel are led by a nurse when providing care to a group of clients. A task approach method is used to provide care to clients- identifies functional nursing. Managed care concepts and tools used when providing client care – identifies a component of case management. The statement a single registered nurse is responsible for providing nursing care to a group of clients- identifies primary nursing.
- Answer B. The nurse must determine the most appropriate assignment on the basis of the skills of the staff member and the needs of the client. In this case, the most appropriate assignment for a nursing assistant would be to care for the client who requires frequent ambulation. The nursing assistant is skilled in this task. The client who had a cardiac catheterization will require specific monitoring in addition to that of the vital signs. Wound irrigations and tube feedings are not performed by unlicensed personnel.
- Answers B, C, D, and F. To prove malpractice against a nurse, the plaintiff must prove that the nurse owed a duty to the client, that the nurse breached the duty, and that as a result harm was caused to person or property. The client has an increased risk of hypotension because hypotension is a common adverse effect of bumetanide, this is the second dose within 4 hours, and the client has heart failure. The client can prove that the nurse did not protect him by failing to provide adequate teaching and perform correct and timely nursing interventions after administering the bumetanide. After the first 15-minute check, the nurse should continue increased client monitoring to ensure client compliance with safety measures. Replacing fluid volume is not the issue; furthermore, the goal of therapy is to reduce total body fluid. No data indicate that the dose of bumetanide, a loop diuretic, was excessive. However, because this medication can cause hypotension, especially after a repeat dose, the nurse should instruct the client to remain in bed and provide him with a urinal. It may be difficult for the client to prove that the second dose of bumetanide caused the injury.