NCLEX-RN Practice Quiz Test Bank #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
Incorrect
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)
Incorrect
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
Incorrect
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
Incorrect
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, epistaxis, visual
dysfunction, diabetes insipidus (DI), and hypotension secondary to
acute hypocortisolism.
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.
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.
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
Incorrect
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)
Incorrect
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
Incorrect
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
Incorrect
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, epistaxis, visual
dysfunction, diabetes insipidus (DI), and hypotension secondary to
acute hypocortisolism.
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.
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.
