Comprehensive NCLEX-RN| Quiz #7: (75 Questions and
Correct Answers/ Rationale (2022 update)
70. Question
Category: Physiological Adaptation
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?
A. BP 146/88
B. Respirations 28 shallow
C. Weight gain of 10 pounds in 6 months
D. Pink complexion
Correct Answer: B. Respirations 28 shallow
When there are fewer red blood cells, there is less hemoglobin and less oxygen. Therefore, the client is
often short of breath.
71. Question
Category: Health Promotion and Maintenance
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?
A. "I will drink 500mL of fluid or less each day."
B. "I will wear support hose when I am up."
C. "I will use an electric razor for shaving."
D. "I will eat foods low in iron."
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
incorrect.
72. Question
Category: Health Promotion and Maintenance
,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?
A. The client collects stamps as a hobby.
B. The client recently lost his job as a postal worker.
C. The client had radiation for treatment of Hodgkin’s disease as a teenager.
D. The client’s brother had leukemia as a child.
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.
73. Question
Category: Health Promotion and Maintenance
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?
A. The abdomen
B. The thorax
C. The earlobes
D. The soles of the feet
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.
74. Question
Category: Health Promotion and Maintenance
A client with acute leukemia is admitted to the oncology unit. Which of the following would be most
important for the nurse to inquire?
A. "Have you noticed a change in sleeping habits recently?"
B. "Have you had a respiratory infection in the last 6 months?"
C. "Have you lost weight recently?"
,D. "Have you noticed changes in your alertness?"
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.
75. Question
Category: Reduction of Risk Potential
Which of the following would be the priority nursing diagnosis for the adult client with acute leukemia?
A. Oral mucous membrane, altered related to chemotherapy
B. Risk for injury related to thrombocytopenia
C. Fatigue related to the disease process
D. Interrupted family processes related to life-threatening illness of a family member
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.
1. Question
Category: Health Promotion and Maintenance
The nurse is providing discharge teaching for the client with leukemia. The client should be told to avoid:
A. Using oil- or cream-based soaps
B. Flossing between the teeth
C. The intake of salt
D. Using an electric razor
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.
2. Question
Category: Reduction of Risk Potential
, The nurse is changing the ties of the client with a tracheostomy. The safest method of changi ng the
tracheostomy ties is to:
A. Apply the new tie before removing the old one.
B. Have a helper present.
C. Hold the tracheostomy with the nondominant hand while removing the old tie.
D. Ask the doctor to suture the tracheostomy in place.
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.
3. Question
Category: Reduction of Risk Potential
The nurse is monitoring a client following a lung resection. The hourly output from the chest tube was
300mL. The nurse should give priority to:
A. Turning the client to the left side
B. Milking the tube to ensure patency
C. Slowing the intravenous infusion
D. Notifying the physician
Correct Answer: D. Notifying the physician
The output of 300 mL is indicative of hemorrhage and should be reported immediately.
4. Question
Category: Pharmacological and Parenteral Therapies
The infant is admitted to the unit with tetralogy of fallot. The nurse would anticipate an order for which
medication?
A. Digoxin
B. Epinephrine
C. Aminophylline
D. Atropine
Correct Answers/ Rationale (2022 update)
70. Question
Category: Physiological Adaptation
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?
A. BP 146/88
B. Respirations 28 shallow
C. Weight gain of 10 pounds in 6 months
D. Pink complexion
Correct Answer: B. Respirations 28 shallow
When there are fewer red blood cells, there is less hemoglobin and less oxygen. Therefore, the client is
often short of breath.
71. Question
Category: Health Promotion and Maintenance
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?
A. "I will drink 500mL of fluid or less each day."
B. "I will wear support hose when I am up."
C. "I will use an electric razor for shaving."
D. "I will eat foods low in iron."
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
incorrect.
72. Question
Category: Health Promotion and Maintenance
,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?
A. The client collects stamps as a hobby.
B. The client recently lost his job as a postal worker.
C. The client had radiation for treatment of Hodgkin’s disease as a teenager.
D. The client’s brother had leukemia as a child.
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.
73. Question
Category: Health Promotion and Maintenance
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?
A. The abdomen
B. The thorax
C. The earlobes
D. The soles of the feet
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.
74. Question
Category: Health Promotion and Maintenance
A client with acute leukemia is admitted to the oncology unit. Which of the following would be most
important for the nurse to inquire?
A. "Have you noticed a change in sleeping habits recently?"
B. "Have you had a respiratory infection in the last 6 months?"
C. "Have you lost weight recently?"
,D. "Have you noticed changes in your alertness?"
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.
75. Question
Category: Reduction of Risk Potential
Which of the following would be the priority nursing diagnosis for the adult client with acute leukemia?
A. Oral mucous membrane, altered related to chemotherapy
B. Risk for injury related to thrombocytopenia
C. Fatigue related to the disease process
D. Interrupted family processes related to life-threatening illness of a family member
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.
1. Question
Category: Health Promotion and Maintenance
The nurse is providing discharge teaching for the client with leukemia. The client should be told to avoid:
A. Using oil- or cream-based soaps
B. Flossing between the teeth
C. The intake of salt
D. Using an electric razor
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.
2. Question
Category: Reduction of Risk Potential
, The nurse is changing the ties of the client with a tracheostomy. The safest method of changi ng the
tracheostomy ties is to:
A. Apply the new tie before removing the old one.
B. Have a helper present.
C. Hold the tracheostomy with the nondominant hand while removing the old tie.
D. Ask the doctor to suture the tracheostomy in place.
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.
3. Question
Category: Reduction of Risk Potential
The nurse is monitoring a client following a lung resection. The hourly output from the chest tube was
300mL. The nurse should give priority to:
A. Turning the client to the left side
B. Milking the tube to ensure patency
C. Slowing the intravenous infusion
D. Notifying the physician
Correct Answer: D. Notifying the physician
The output of 300 mL is indicative of hemorrhage and should be reported immediately.
4. Question
Category: Pharmacological and Parenteral Therapies
The infant is admitted to the unit with tetralogy of fallot. The nurse would anticipate an order for which
medication?
A. Digoxin
B. Epinephrine
C. Aminophylline
D. Atropine
