NCLEX Practice Exam 5 â Questions and Answers
Question 1: 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?
- Palpate the spleen
- Take the blood pressure
- Examine the feet for petechiae
- Examine the tongue (Correct answer)
Correct answer: Examine the tongue
Vitamin B12 deficiency, often associated with pernicious anemia, commonly manifests as glossitis. This condition causes the tongue to appear smooth, beefy red, and sore due to the atrophy of the papillae. Therefore, examining the tongue is a crucial part of the physical assessment for this client.
Question 2: The Hodgkinâs disease patient described in the question above undergoes a lymph node biopsy for definitive diagnosis. If the diagnosis of Hodgkinâs disease were correct, which of the following cells would the pathologist expect to find?
- Reed-Sternberg cells. (Correct answer)
- Lymphoblastic cells.
- Gaucherâs cells.
- Riederâs cells
Correct answer: Reed-Sternberg cells.
Reed-Sternberg cells are large, distinctive abnormal lymphocytes that are considered the pathological hallmark of Hodgkin's lymphoma. Their presence in a lymph node biopsy is essential for a definitive diagnosis of Hodgkin's disease. Pathologists specifically look for these cells to confirm the diagnosis.
Question 3: 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.
- Adjust the room temperature
- Give a bolus of IV fluids
- Start O2 (Correct answer)
- Administer meperidine (Demerol) 75 mg IV push
Correct answer: Start O2
In sickle cell crisis, the primary problem is vaso-occlusion and tissue hypoxia caused by sickled red blood cells. Hypoxia further exacerbates sickling, creating a dangerous cycle. Administering oxygen first is crucial to improve tissue oxygenation, reduce sickling, and alleviate the severe pain, making it the immediate priority intervention.
Question 4: 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?
- Conjunctiva of the eye
- Soles of the feet
- Roof of the mouth (Correct answer)
- Shins
Correct answer: Roof of the mouth
Jaundice, a yellow discoloration, can be challenging to detect in individuals with darker skin tones. The roof of the mouth (hard palate) is a mucous membrane that typically has less pigmentation than the skin. This makes it a more reliable and accurate site for assessing the yellowish tint indicative of jaundice.
Question 5: 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 abdomen
- The thorax
- The earlobes
- The soles of the feet (Correct answer)
Correct answer: The soles of the feet
Petechiae, which are tiny pinpoint hemorrhages, can be difficult to visualize on darker skin. The soles of the feet, along with the palms of the hands and mucous membranes, are areas where the skin is naturally lighter and less pigmented. This allows for easier and more accurate detection of petechiae in African American clients.
Question 6: 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?
- Increases fitness and prevents future heart attacks.
- Prevents bedsores.
- Prevents DVT (deep vein thrombosis). (Correct answer)
- Prevent constipations.
Correct answer: Prevents DVT (deep vein thrombosis).
After a myocardial infarction, patients are at an increased risk for deep vein thrombosis (DVT) due to immobility and hypercoagulability. Frequent leg exercises and ambulation promote venous return from the lower extremities, preventing blood stasis. This active movement significantly reduces the risk of clot formation and DVT.
Question 7: A hospitalized patient is receiving packed red blood cells (PRBCs) for treatment of severe anemia. Which of the following is the most accurate statement?
- Transfusion reaction is most likely immediately after the infusion is completed.
- PRBCs are best infused slowly through a 20g. IV catheter.
- PRBCs should be flushed with a 5% dextrose solution.
- A nurse should remain in the room during the first 15 minutes of infusion. (Correct answer)
Correct answer: A nurse should remain in the room during the first 15 minutes of infusion.
The most severe and life-threatening transfusion reactions typically occur within the first 15 minutes of a blood product infusion. Remaining with the patient during this critical period allows the nurse to promptly identify any adverse reactions. Immediate recognition and intervention are vital for patient safety and to prevent serious complications.
Question 8: A client with hemophilia has a nosebleed. Which nursing action is most appropriate to control the bleeding?
- Place the client in a sitting position with the head hyperextended
- Pack the nares tightly with gauze to apply pressure to the source of bleeding
- Pinch the soft lower part of the nose for a minimum of 5 minutes (Correct answer)
- Apply ice packs to the forehead and back of the neck
Correct answer: Pinch the soft lower part of the nose for a minimum of 5 minutes
Pinching the soft lower part of the nose applies direct pressure to the blood vessels in Kiesselbach's plexus, which is the most common site for anterior nosebleeds. This pressure helps to constrict the vessels and promote clot formation, making it the most effective initial intervention for epistaxis, especially in a client with hemophilia where clotting is impaired.
Question 9: 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 books and magazines for entertainment.
- We will bring in personal care items for comfort.
- We will bring in fresh flowers to brighten the room. (Correct answer)
- We will bring in family pictures and get well cards.
Correct answer: We will bring in fresh flowers to brighten the room.
Fresh flowers and plants can harbor mold, bacteria, and fungi in their soil and water. For a patient undergoing leukemia treatment, who is severely immunocompromised, these microorganisms pose a significant risk of infection. Therefore, bringing fresh flowers indicates a lack of understanding regarding infection control precautions.
Question 10: Dave, a 6-year-old boy, was rushed to the hospital following her motherâs complaint that her son has been vomiting, nauseated and has overall weakness. After series of tests, the nurse notes the laboratory results: potassium: 2.9 mEq. Which primary acid-base imbalance is this boy at risk for if medical intervention is not carried out?
- Respiratory Acidosis
- Respiratory Alkalosis
- Metabolic Acidosis
- Metabolic Alkalosis (Correct answer)
Correct answer: Metabolic Alkalosis
Prolonged or severe vomiting leads to a significant loss of gastric acid (hydrochloric acid) from the body. This loss results in a net increase of bicarbonate, shifting the body's pH towards alkalinity. The accompanying hypokalemia also contributes to the development of metabolic alkalosis.
Question 11: An old beggar was admitted to the emergency department due to shortness of breath, fever, and a productive cough. Upon examination, crackles and wheezes are noted in the lower lobes; he appears to be tachycardic and has a bounding pulse. Measurement of arterial blood gas shows pH 7.2, PaCO2 66 mm Hg, HCO3 27 mmol/L, and PaO2 65 mm Hg. As a knowledgeable nurse, you know that the normal value for pH is:
- 7.2
- 7.3
- 7.4 (Correct answer)
- 7.5
Correct answer: 7.4
The normal physiological range for arterial blood pH is tightly regulated between 7.35 and 7.45. A pH of 7.4 represents the ideal midpoint within this narrow range. Maintaining pH within these limits is crucial for proper cellular function and enzyme activity.
Question 12: Liza's mother is seen in the emergency department at a community hospital. She admits that her mother is taking many tablets of aspirin (salicylates) over the last 24-hour period because of a severe headache. Also, the mother complains of an inability to urinate. The nurse on duty took her vital signs and noted the following: Temp = 97.8 °F; apical pulse = 95; respiration = 32 and deep. Which primary acid-base imbalance is the client at risk for if medical attention is not provided?
- Respiratory Acidosis
- Respiratory Alkalosis
- Metabolic Acidosis (Correct answer)
- Metabolic Alkalosis
Correct answer: Metabolic Acidosis
Aspirin (salicylate) overdose initially stimulates the respiratory center, leading to hyperventilation and respiratory alkalosis. However, as the overdose progresses, the accumulation of salicylic acid and other organic acids overwhelms the body's buffering systems. This leads to a severe metabolic acidosis, which is the primary acid-base imbalance at risk.
Question 13: A patient who is hospitalized due to vomiting and a decreased level of consciousness displays slow and deep (Kussmaul breathing), and he is lethargic and irritable in response to stimulation. The doctor diagnosed him of having dehydration. Measurement of arterial blood gas shows pH 7.0, PaO2 90 mm Hg, PaCO2 22 mm Hg, and HCO3 14 mmol/L; other results are Na+ 120 mmol/L, K+ 2.5 mmol/L, and Cl- 95 mmol/L. As a knowledgeable nurse, you know that the normal value for PaCO2 is:
- 22 mm Hg
- 36 mm Hg (Correct answer)
- 48 mm Hg
- 50 mm Hg
Correct answer: 36 mm Hg
The normal range for the arterial partial pressure of carbon dioxide (PaCO2) is 35-45 mm Hg. This value reflects the ventilatory status and the amount of carbon dioxide in the blood. A PaCO2 of 36 mm Hg falls perfectly within this normal physiological range.
Question 14: A company driver is found at the scene of an automobile accident in a state of emotional distress. He tells the paramedics that he feels dizzy, tingling in his fingertips, and does not remember what happened to his car. Respiratory rate is rapid at 34/minute. Which primary acid-base disturbance is the young man at risk for if medical attention is not provided?
- Respiratory Acidosis
- Respiratory Alkalosis (Correct answer)
- Metabolic Acidosis
- Metabolic Alkalosis
Correct answer: Respiratory Alkalosis
Emotional distress and anxiety often trigger hyperventilation, characterized by rapid and deep breathing. This excessive exhalation of carbon dioxide (CO2) leads to a decrease in the arterial partial pressure of CO2 (PaCO2). A low PaCO2 causes the blood pH to rise, resulting in respiratory alkalosis.
Question 15: An old man was admitted to hospital in a coma. Analysis of the arterial blood gave the following values: PCO2 16 mm Hg, HCO3- 5 mmol/L and pH 7.1. As a well-rounded nurse, you know that the normal value for HCO3 is:
- 20 mmol/L
- 24 mmol/L (Correct answer)
- 29 mmol/L
- 31 mmol/L
Correct answer: 24 mmol/L
The normal physiological range for bicarbonate (HCO3-) in arterial blood is 22-26 mmol/L. Bicarbonate is a crucial component of the body's buffer system, helping to maintain acid-base balance. Therefore, 24 mmol/L is considered a normal and ideal value for HCO3-.
Question 16: In a patient undergoing surgery, it was vital to aspirate the contents of the upper gastrointestinal tract. After the operation, the following values were acquired from an arterial blood sample: pH 7.55, PCO2 52 mm Hg and HCO3- 40 mmol/l. What is the underlying disorder?
- Respiratory Acidosis
- Respiratory Alkalosis
- Metabolic Acidosis
- Metabolic Alkalosis (Correct answer)
Correct answer: Metabolic Alkalosis
The arterial blood gas results show a high pH (7.55) indicating alkalosis, and a significantly elevated bicarbonate (HCO3- 40 mmol/L). The elevated PCO2 (52 mm Hg) suggests respiratory compensation for the alkalosis. Aspiration of upper gastrointestinal contents removes gastric acid, leading to a net increase in bicarbonate and causing a primary metabolic alkalosis.
NCLEX Practice Exam 5
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?