NCLEX Practice Exam 5 (45 Items)/ TOP RATED PAPER/ Already GRADED A

NCLEX Practice Exam 5 (45 Items) A nurse is administering IV furosemide to a patient admitted with congestive heart failure. After the infusion, which of the following symptoms is NOT expected? Decreased edema. Decreased blood pressure. There are a number of risk factors associated with coronary artery disease. Which of the following is a modifiable risk factor? Heredity. Age. Tissue plasminogen activator (t-PA) is considered for treatment of a patient who arrives in the emergency department following onset of symptoms of myocardial infarction. Which of the following is a contraindication for treatment with t-PA? History of cerebral hemorrhage. Hypertension. Following myocardial infarction, a hospitalized patient is encouraged to practice frequent leg exercises and ambulate in the hallway as directed by his physician. Which of the following choices reflects the purpose of exercise for this patient? Prevents bedsores. Prevent constipations. A patient arrives in the emergency department with symptoms of myocardial infarction, progressing to cardiogenic shock. Which of the following symptoms should the nurse expect the patient to exhibit with cardiogenic shock? Bradycardia. Confusion. A patient with a history of congestive heart failure arrives at the clinic complaining of dyspnea. Which of the following actions is the first the nurse should perform? Draw blood for chemistry panel and arterial blood gas (ABG). Check blood pressure. A clinic patient has recently been prescribed nitroglycerin for treatment of angina. He calls the nurse complaining of frequent headaches. Which of the following responses to the patient is correct? “Go to the emergency department to be checked because nitroglycerin can cause bleeding in the brain.” “The headaches are unlikely to be related to the nitroglycerin, so you should see your doctor for further investigation.” A patient received surgery and chemotherapy for colon cancer, completing therapy 3 months previously, and she is now in remission. At a follow-up appointment, she complains of fatigue following activity and difficulty with concentration at her weekly bridge games. Which of the following explanations could account for her symptoms? The patient may be immunosuppressed. The patient may be dehydrated. A clinic patient has a hemoglobin concentration of 10.8 g/dL and reports sticking to a strict vegetarian diet. Which of the follow nutritional advice is appropriate? The patient should add meat to her diet; a vegetarian diet is not advised. A cup of coffee or tea should be added to every meal. A hospitalized patient is receiving packed red blood cells (PRBCs) for treatment of severe anemia. Which of the following is the most accurate statement? PRBCs are best infused slowly through a 20g. IV catheter. A nurse should remain in the room during the first 15 minutes of infusion. A patient who has received chemotherapy for cancer treatment is given an injection of Epoetin. Which of the following should reflect the findings in a complete blood count (CBC) drawn several days later? An increase in hematocrit. An increase in serum iron. A patient is admitted to the hospital with suspected polycythemia vera. Which of the following symptoms is consistent with the diagnosis? Select all that applies. Increased clotting time. Headaches. A nurse is caring for a patient with a platelet count of 20,000/microliter. Which of the following is an important intervention? Limit visitors to family only. Impose immune precautions. A nurse in the emergency department assesses a patient who has been taking long-term corticosteroids to treat renal disease. Which of the following is a typical side effect of corticosteroid treatment? Note: More than one answer may be correct. Cushingoid features. Low serum albumin. A nurse is caring for patients in the oncology unit. Which of the following is the most important nursing action when caring for a neutropenic patient? Change gloves immediately after use. Minimize conversation with the patient. A patient is undergoing the induction stage of treatment for leukemia. The nurse teaches family members about infectious precautions. Which of the following statements by family members indicates that the family needs more education? We will bring in personal care items for comfort. We will bring in family pictures and get well cards. A nurse is caring for a patient with acute lymphoblastic leukemia (ALL). Which of the following is the most likely age range of the patient? 25-35 years. over 60 years. A patient is admitted to the oncology unit for diagnosis of suspected Hodgkin’s disease. Which of the following symptoms is typical of Hodgkin’s disease? Night sweats and fatigue. Weight gain. The Hodgkin’s disease patient described in the question above undergoes a lymph node biopsy for definitive diagnosis. If the diagnosis of Hodgkin’s disease were correct, which of the following cells would the pathologist expect to find? Lymphoblastic cells. Rieder’s cells A patient is about to undergo bone marrow aspiration and biopsy and expresses fear and anxiety about the procedure. Which of the following is the most effective nursing response? Encourage the family to stay in the room for the procedure. Delay the procedure to allow the patient to deal with her feelings. 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? Toes moved in active range of motion Capillary refill of 3 seconds 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? Knee-chest Semi-Fowler’s with legs extended on the bed A 25-year-old male is admitted in sickle cell crisis. Which of the following interventions would be of highest priority for this client? Encouraging fluid intake of at least 200mL per hour Administering Tylenol as ordered Question 23 Explanation: Which of the following foods would the nurse encourage the client in sickle cell crisis to eat? Cottage cheese Lima beans 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. Give a bolus of IV fluids Administer meperidine (Demerol) 75 mg IV push The nurse is instructing a client with iron-deficiency anemia. Which of the following meal plans would the nurse expect the client to select? Chicken salad sandwich, coleslaw, French fries, ice cream Pork chop, creamed potatoes, corn, and coconut cake Clients with sickle cell anemia are taught to avoid activities that cause hypoxia and hypoxemia. Which of the following activities would the nurse recommend? Chaperoning the local boys club on a snow-skiing trip A bus trip to the Museum of Natural History 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? Take the blood pressure Examine the tongue 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? Soles of the feet Shins 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? Respirations 28 shallow Pink complexion 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 wear support hose when I am up.” “I will eat foods low in iron.” 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 recently lost his job as a postal worker. The client’s brother had leukemia as a child. 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 thorax The soles of the feet 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 had a respiratory infection in the last 6 months?” “Have you noticed changes in your alertness?” Which of the following would be the priority nursing diagnosis for the adult client with acute leukemia? Risk for injury related to thrombocytopenia Interrupted family processes related to life-threatening illness of a family member 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? Anticipatory grieving related to terminal illness Fatigue related to chemotherapy A client has autoimmune thrombocytopenic purpura. To determine the client’s response to treatment, the nurse would monitor: White blood cell count Partial prothrombin time (PTT) 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: Prevention of falls Conservation of energy A client with a pituitary tumor has had a transsphenoidal hypophysectomy. Which of the following interventions would be appropriate for this client? Encourage coughing and deep breathing every 2 hours Encourage the Valsalva maneuver for bowel movements The client with a history of diabetes insipidus is admitted with polyuria, polydipsia, and mental confusion. The priority intervention for this client is: Check the vital signs Weigh the client A client with hemophilia has a nosebleed. Which nursing action is most appropriate to control the bleeding? Pack the nares tightly with gauze to apply pressure to the source of bleeding Apply ice packs to the forehead and back of the neck A client has had a unilateral adrenalectomy to remove a tumor. To prevent complications, the most important measurement in the immediate postoperative period for the nurse to take is: Temperature Specific gravity 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? Intake/output measurements Daily weights 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? Check the calcium level Assess the blood pressure for hypertension 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? Hypothermia r/t decreased metabolic rate Decreased cardiac output r/t bradycardia Show Less