NCLEX-RN Practice Questions Set 8
(75 Questions)
1. 1. Question
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?
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
Correct Answer: A. Sexual dysfunction related to radiation
therapy
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. Know the importance of sex to individual,
partner, and patient’s motivation for change. Because
lymphomas often affect the relatively young who are in their
productive years, these people may be affected more by these
problems and may be less knowledgeable about the possibilities
of change.
Option B: Grieving may not be an appropriate
diagnosis since the client would be experiencing new
milestones in his life despite his condition. Let the
patient describe the problem in own words. Provides a
more accurate picture of patient experience with
which to develop a plan of care.
Option C: Option B is not applicable since the client is
not on bed rest. Encourage the patient to share
thoughts and concerns with his partner and to clarify
values and impact of condition on relationship. Helps
, the couple begin to deal with issues that can
strengthen or weaken the relationship.
Option D: Fatigue may occur during chemotherapy,
but it is not the priority diagnosis. Identify pre-existing
and current stress factors that may be affecting the
relationship. The patient may be concerned about
other issues, such as job, financial, and illness-related
problems.
2. 2. Question
A client has autoimmune thrombocytopenic purpura. To
determine the client’s response to treatment, the nurse would
monitor:
A. Platelet count
B. White blood cell count
C. Potassium levels
D. Partial prothrombin time (PTT)
Correct Answer: A. Platelet count
Clients with autoimmune thrombocytopenic purpura (ATP) have
low platelet counts, making answer A the correct answer. The
laboratory tests will show low platelet count, usually <40×10^9/L
for over three months. Blood film shows large platelets and tiny
platelet fragments. Bone marrow examination shows an
increased number of megakaryocytes.
Option B: Often associated with the CBC is a
differential, which refers to the relative amounts of
white blood cell types (i.e., neutrophil, lymphocyte,
eosinophil, etc.) as a percentage of the total number
of WBCs. Of note, if a subtype of white blood cells
seems to be elevated based on the differential, the
actual value of the type of white blood cells should be
calculated by multiplying the percentage listed on the
differential by the total number of white blood cells.
Option C: Potassium disorders are related to cardiac
arrhythmias. Hypokalemia occurs when serum
potassium levels under 3.6 mmol/L—weakness,
, fatigue, and muscle twitching present in hypokalemia.
Hyperkalemia occurs when the serum potassium
levels above 5.5 mmol/L, which can result in
arrhythmias. Muscle cramps, muscle weakness,
rhabdomyolysis, myoglobinuria are presenting signs
and symptoms in hyperkalemia.
Option D: Patients with a propensity for bleeding
should undergo testing to determine the presence of a
clotting disorder. For patients with deficiencies or
defects of the intrinsic clotting cascade, the PTT will be
elevated. Normal PTT values can vary between
laboratories but 25 to 35 seconds is considered
normal.
3. 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:
A. Bleeding precautions
B. Prevention of falls
C. Oxygen therapy
D. Conservation of energy
Correct Answer: A. Bleeding precautions
The normal platelet count is 120,000–400, Bleeding occurs in
clients with low platelets. The priority is to prevent and minimize
bleeding. Review laboratory results for coagulation status as
appropriate: platelet count, prothrombin time/international
normalized ratio (PT/INR), activated partial thromboplastin time
(aPTT), fibrinogen, bleeding time, fibrin degradation products,
vitamin K, activated coagulation time (ACT); and educate the at-
risk patient and caregivers about precautionary measures to
prevent tissue trauma or disruption of the normal clotting
mechanisms.
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.
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.
Option D: Option D is of lesser priority and is
incorrect 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. 4. Question
A client with a pituitary tumor has had transsphenoidal
hypophysectomy. Which of the following interventions would be
appropriate for this client?
A. Place the client in Trendelenburg position for postural
drainage
B. Encourage coughing and deep breathing every 2
hours
C. Elevate the head of the bed 30°
D. Encourage the Valsalva maneuver for bowel
movements
Correct Answer: C. Elevate the head of the bed 30°
Elevating the head of the bed 30° avoids pressure on the sella
turcica and alleviates headaches. A, B, and D are incorrect. In the
immediate postoperative period, patients are monitored in an
intensive care unit with monitoring for neurological deterioration,
(75 Questions)
1. 1. Question
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?
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
Correct Answer: A. Sexual dysfunction related to radiation
therapy
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. Know the importance of sex to individual,
partner, and patient’s motivation for change. Because
lymphomas often affect the relatively young who are in their
productive years, these people may be affected more by these
problems and may be less knowledgeable about the possibilities
of change.
Option B: Grieving may not be an appropriate
diagnosis since the client would be experiencing new
milestones in his life despite his condition. Let the
patient describe the problem in own words. Provides a
more accurate picture of patient experience with
which to develop a plan of care.
Option C: Option B is not applicable since the client is
not on bed rest. Encourage the patient to share
thoughts and concerns with his partner and to clarify
values and impact of condition on relationship. Helps
, the couple begin to deal with issues that can
strengthen or weaken the relationship.
Option D: Fatigue may occur during chemotherapy,
but it is not the priority diagnosis. Identify pre-existing
and current stress factors that may be affecting the
relationship. The patient may be concerned about
other issues, such as job, financial, and illness-related
problems.
2. 2. Question
A client has autoimmune thrombocytopenic purpura. To
determine the client’s response to treatment, the nurse would
monitor:
A. Platelet count
B. White blood cell count
C. Potassium levels
D. Partial prothrombin time (PTT)
Correct Answer: A. Platelet count
Clients with autoimmune thrombocytopenic purpura (ATP) have
low platelet counts, making answer A the correct answer. The
laboratory tests will show low platelet count, usually <40×10^9/L
for over three months. Blood film shows large platelets and tiny
platelet fragments. Bone marrow examination shows an
increased number of megakaryocytes.
Option B: Often associated with the CBC is a
differential, which refers to the relative amounts of
white blood cell types (i.e., neutrophil, lymphocyte,
eosinophil, etc.) as a percentage of the total number
of WBCs. Of note, if a subtype of white blood cells
seems to be elevated based on the differential, the
actual value of the type of white blood cells should be
calculated by multiplying the percentage listed on the
differential by the total number of white blood cells.
Option C: Potassium disorders are related to cardiac
arrhythmias. Hypokalemia occurs when serum
potassium levels under 3.6 mmol/L—weakness,
, fatigue, and muscle twitching present in hypokalemia.
Hyperkalemia occurs when the serum potassium
levels above 5.5 mmol/L, which can result in
arrhythmias. Muscle cramps, muscle weakness,
rhabdomyolysis, myoglobinuria are presenting signs
and symptoms in hyperkalemia.
Option D: Patients with a propensity for bleeding
should undergo testing to determine the presence of a
clotting disorder. For patients with deficiencies or
defects of the intrinsic clotting cascade, the PTT will be
elevated. Normal PTT values can vary between
laboratories but 25 to 35 seconds is considered
normal.
3. 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:
A. Bleeding precautions
B. Prevention of falls
C. Oxygen therapy
D. Conservation of energy
Correct Answer: A. Bleeding precautions
The normal platelet count is 120,000–400, Bleeding occurs in
clients with low platelets. The priority is to prevent and minimize
bleeding. Review laboratory results for coagulation status as
appropriate: platelet count, prothrombin time/international
normalized ratio (PT/INR), activated partial thromboplastin time
(aPTT), fibrinogen, bleeding time, fibrin degradation products,
vitamin K, activated coagulation time (ACT); and educate the at-
risk patient and caregivers about precautionary measures to
prevent tissue trauma or disruption of the normal clotting
mechanisms.
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.
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.
Option D: Option D is of lesser priority and is
incorrect 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. 4. Question
A client with a pituitary tumor has had transsphenoidal
hypophysectomy. Which of the following interventions would be
appropriate for this client?
A. Place the client in Trendelenburg position for postural
drainage
B. Encourage coughing and deep breathing every 2
hours
C. Elevate the head of the bed 30°
D. Encourage the Valsalva maneuver for bowel
movements
Correct Answer: C. Elevate the head of the bed 30°
Elevating the head of the bed 30° avoids pressure on the sella
turcica and alleviates headaches. A, B, and D are incorrect. In the
immediate postoperative period, patients are monitored in an
intensive care unit with monitoring for neurological deterioration,
