NCLEX-RN Exam Pack Set 8 (75 Questions & Answers Updated 2022)
1. 1. Question
A 21-year-old male with Hodgkin’s lymphoma is a senior at the local
... [Show More] 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?
o A. Sexual dysfunction related to radiation therapy
o B. Anticipatory grieving related to terminal illness
o C. Tissue integrity related to prolonged bed rest
o D. Fatigue related to chemotherapy
• 2. Question
A client has autoimmune thrombocytopenic purpura. To determine the client’s response to treatment, the nurse would monitor:
o A. Platelet count
o B. White blood cell count
o C. Potassium levels
o D. Partial prothrombin time (PTT)
• 3. Question
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:
o A. Bleeding precautions
o B. Prevention of falls
o C. Oxygen therapy
o D. Conservation of energy
risk patient and caregivers about precautionary measures to prevent tissue trauma or disruption of the normal clotting mechanisms.
o Option B: Thoroughly conform patient to surroundings; put call light within reach and teach how to call for assistance; respond to call light immediately; avoid use of restraints; obtain a physician’s order if restraints are needed; and eliminate or drop all possible hazards in the room such as razors, medications, and matches.
o Option C: Option C is important, but platelets do not carry oxygen. Wash hands and teach patient and SO to wash hands before contact with patients and between procedures with the patient; encourage fluid intake of 2,000 to 3,000 mL of water per day, unless contraindicated.
o Option D: Option D is of lesser priority and is in this instance. Recommend the use of soft-bristled toothbrushes and stool softeners to protect mucous membranes; and if infection occurs, teach the patient to take antibiotics as prescribed; instruct the patient to take the full course of antibiotics even if symptoms improve or disappear.
• 4. Question
A client with a pituitary tumor has had transsphenoidal hypophysectomy. Which of the following interventions would be appropriate for this client?
o A. Place the client in Trendelenburg position for postural drainage
o B. Encourage coughing and deep breathing every 2 hours
o C. Elevate the head of the bed 30°
o D. Encourage the Valsalva maneuver for bowel movements
Elevating the head of the bed 30° avoids pressure on the sella turcica and alleviates headaches. A, B, and D are . In the immediate postoperative period, patients are monitored in an intensive care unit with monitoring for neurological deterioration, epistaxis, visual dysfunction, diabetes insipidus (DI), and hypotension secondary to acute hypocortisolism.
o Option A: Placing the patient in Trendelenburg will increase the intracranial pressure. The most common complications are CSF leak, sinusitis, and meningitis. CSF leaks, occurring in 6 in every 100 cases, is usually prevented by a multilayer closure at the end of surgery. In the occurrence of a leak in the postoperative period, the patient is advised bed rest, and a lumbar drain is placed. If the leak does not improve in 24 hours, exploration and closure of the defect are to be done.
o Option B: Coughing and deep breathing causes increase in intracranial pressure. Worsening of vision as a result of bleeding or manipulation and arterial hemorrhage are other immediate complications. A detailed study of preoperative imaging is essential to avoid catastrophes like optic nerve and carotid artery injury.
o Option D: Valsalva maneuver increases the intracranial pressure. The first follow up visit is 1 week after the procedure, where postoperative day 7 serum sodium levels are reviewed to rule out occult hyponatremia. Serial nasal endoscopies are done for debridement and to assess healing. The frequency of follow-up visits is determined by nasal crusting and maintenance of nasal hygiene with irrigation. Routine early postoperative imaging is not done in most patients.
• 5. Question
The client with a history of diabetes insipidus is admitted with polyuria, polydipsia, and mental confusion. The priority intervention for this client is:
o A. Measure the urinary output
o B. Check the vital signs
o C. Encourage increased fluid intake
o D. Weigh the client
Correct Answer: B. Check the vital signs
A 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. Monitor for signs of hypovolemic shock (e.g., tachycardia, tachypnea, hypotension). Frequent assessment can detect changes early for rapid intervention. Polyuria causes decreased circulatory blood volume.
o Option A: Measuring the urinary output is important, but the stem already says that the client has polyuria. Monitor intake and output. Report urine volume greater than 200 mL for each of 2 consecutive hours or 500 mL in a 2-hour period. With DI, the patient voids large urine volumes independent of the fluid intake. Urine output ranges from 2 to 3 L/day with renal DI to greater than 10 L/day with central DI.
o Option C: Encouraging fluid intake will not correct the problem. Allow the patient to drink water at will. Patients with intact thirst mechanisms may maintain fluid balance by drinking huge quantities of water to compensate for the amount they urinate. Patients prefer cold or ice water.
o Option D: Weighing the client is not necessary at this time. Monitor serum and urine osmolality. Urine osmolality will be decreased and serum osmolality will increase. Monitor urine-specific gravity. This may be
1.005 or less.
• 6. Question
A client with hemophilia has a nosebleed. Which nursing action is most appropriate to control the bleeding?
o A. Place the client in a sitting position with the head hyperextended [Show Less]