NCLEX-RN Practice Quiz Test Bank #8
(75 Questions)
NCLEXRN-08-001
Question Tag: Hodgkin’s lymphoma
Question Category: Physiological Integrity
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?
A. Sexual dysfunction related to radiation therapy
B. Anticipatory grieving related to terminal illness
C. Tissue integrity related to prolonged bed rest
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 their 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.
NCLEXRN-08-002
Question Tag: thrombocytopenic purpura
Question Category: Physiological Integrity
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.
NCLEXRN-08-003
Question Tag: thrombocytopenic purpura
Question Category: Physiological Integrity
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.
NCLEXRN-08-004
Question Tag: transsphenoidal hypophysectomy
Question Category: Physiological Integrity
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
(75 Questions)
NCLEXRN-08-001
Question Tag: Hodgkin’s lymphoma
Question Category: Physiological Integrity
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?
A. Sexual dysfunction related to radiation therapy
B. Anticipatory grieving related to terminal illness
C. Tissue integrity related to prolonged bed rest
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 their 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.
NCLEXRN-08-002
Question Tag: thrombocytopenic purpura
Question Category: Physiological Integrity
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.
NCLEXRN-08-003
Question Tag: thrombocytopenic purpura
Question Category: Physiological Integrity
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.
NCLEXRN-08-004
Question Tag: transsphenoidal hypophysectomy
Question Category: Physiological Integrity
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
