NCLEX-RN Practice Test 10 — Questions and Answers

Question 1: 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 drink 500mL of fluid or less each day.” (Correct answer)
“I will wear support hose when I am up.”
“I will use an electric razor for shaving.”
“I will eat foods low in iron.”

Correct answer: “I will drink 500mL of fluid or less each day.”

Polycythemia vera is characterized by an overproduction of red blood cells, increasing blood viscosity and the risk of blood clots. Adequate hydration is crucial to help reduce blood viscosity and prevent thrombotic events. Therefore, limiting fluid intake to 500mL or less would worsen the condition and indicates a need for further teaching.

Question 2: 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?

Glucometer readings as ordered (Correct answer)
Intake/output measurements
Sodium and potassium levels monitored
Daily weights

Correct answer: Glucometer readings as ordered

Glucocorticoids like Solu-Medrol are known to cause hyperglycemia by increasing glucose production and decreasing glucose utilization. In a client with Addison's disease, who is also experiencing stress from nausea and vomiting, monitoring blood glucose levels is essential to detect and manage potential steroid-induced hyperglycemia.

Question 3: There are a number of risk factors associated with coronary artery disease. Which of the following is a modifiable risk factor?

Obesity (Correct answer)
Heredity.
Gender.
Age

Correct answer: Obesity

Modifiable risk factors are those that can be changed or controlled through lifestyle interventions or medical treatment. Obesity is a modifiable risk factor for coronary artery disease because it can be managed through diet, exercise, and other weight-loss strategies, unlike non-modifiable factors such as heredity, gender, and age.

Question 4: 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 noticed a change in sleeping habits recently?”
“Have you had a respiratory infection in the last 6 months?” (Correct answer)
“Have you lost weight recently?”
“Have you noticed changes in your alertness?”

Correct answer: “Have you had a respiratory infection in the last 6 months?”

Acute leukemia is a cancer that impairs the body's ability to produce healthy white blood cells, leading to severe immunosuppression. Clients with leukemia are highly susceptible to infections, making inquiries about recent respiratory infections crucial for assessing their current health status and identifying potential life-threatening complications.

Question 5: 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?

Painful cervical lymph nodes.
Night sweats and fatigue. (Correct answer)
Nausea and vomiting.
Weight gain.

Correct answer: Night sweats and fatigue.

Hodgkin's disease, a type of lymphoma, is often characterized by systemic 'B symptoms,' which include unexplained fever, drenching night sweats, and significant weight loss. Fatigue is also a common symptom due to the body's response to the cancer. These symptoms are key diagnostic indicators.

Question 6: 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?

Increased urinary output.
Decreased edema.
Decreased pain. (Correct answer)
Decreased blood pressure.

Correct answer: Decreased pain.

Furosemide is a loop diuretic primarily used to treat fluid overload in conditions like congestive heart failure. Its expected effects include increased urinary output, decreased edema, and decreased blood pressure due to fluid removal. Furosemide does not possess analgesic properties, so decreased pain is not an anticipated outcome.

Question 7: A nurse is caring for a patient with a platelet count of 20,000/microliter. Which of the following is an important intervention?

Observe for evidence of spontaneous bleeding. (Correct answer)
Limit visitors to family only.
Give aspirin in case of headaches.
Impose immune precautions.

Correct answer: Observe for evidence of spontaneous bleeding.

A platelet count of 20,000/microliter is critically low, indicating severe thrombocytopenia. At this level, there is a significant risk of spontaneous bleeding, including petechiae, purpura, epistaxis, and internal hemorrhage. Close observation for any evidence of bleeding is the highest priority intervention to prevent serious complications.

Question 8: 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?

Impaired physical mobility related to decreased endurance
Hypothermia r/t decreased metabolic rate
Disturbed thought processes r/t interstitial edema
Decreased cardiac output r/t bradycardia (Correct answer)

Correct answer: Decreased cardiac output r/t bradycardia

Hypothyroidism significantly slows the body's metabolic rate, directly impacting cardiac function and leading to bradycardia (pulse 52). This decreased heart rate can result in insufficient blood circulation to meet the body's demands, making decreased cardiac output the highest priority nursing diagnosis due to its potential for life-threatening complications.

Question 9: 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?

Body temperature of 99°F or less
Toes moved in active range of motion
Sensation reported when soles of feet are touched
Capillary refill of < 3 seconds (Correct answer)

Correct answer: Capillary refill of < 3 seconds

Sickle cell anemia can cause vaso-occlusive crises, leading to impaired circulation, particularly in the extremities. Capillary refill time is a direct and objective indicator of peripheral perfusion. A capillary refill of less than 3 seconds indicates adequate blood flow, which is a crucial outcome criterion when assessing circulation in a client with sickle cell disease.

Question 10: A client with a history of emboli is receiving Lovenox (enoxaparin). Which drug is given to counteract the effects of enoxaparin?

Calcium gluconate
Aquamephyton
Methergine
Protamine sulfate (Correct answer)

Correct answer: Protamine sulfate

Enoxaparin (Lovenox) is a low molecular weight heparin, an anticoagulant used to prevent blood clots. Protamine sulfate is the specific antidote used to reverse the anticoagulant effects of heparin and low molecular weight heparins like enoxaparin. It works by forming a stable complex with heparin, neutralizing its activity.

Question 11: The nurse is formulating a plan of care for a client with a cognitive disorder. Which activity is most appropriate for the client with confusion and short attention span?

Taking part in a reality-orientation group (Correct answer)
Participating in unit community goal setting
Going on a field trip with a group of clients
Meeting with an assertiveness training group

Correct answer: Taking part in a reality-orientation group

For clients with confusion and a short attention span, reality-orientation groups are most appropriate because they provide a structured, repetitive environment that helps reinforce basic information about time, place, and person. This therapeutic approach aims to reduce confusion and improve cognitive function by consistently reorienting the client to their current reality, which is manageable given their limited attention span.

Question 12: The mother of a child with hemophilia asks the nurse which over-the-counter medication is suitable for her child’s joint discomfort. The nurse should tell the mother to purchase:

Advil (ibuprofen)
Tylenol (acetaminophen) (Correct answer)
Aspirin (acetylsalicylic acid)
Naproxen (naprosyn)

Correct answer: Tylenol (acetaminophen)

Tylenol (acetaminophen) is the safest over-the-counter medication for joint discomfort in a child with hemophilia because it provides pain relief without affecting platelet function or blood clotting. NSAIDs like ibuprofen (Advil) and naproxen (Naprosyn), along with aspirin, inhibit platelet aggregation and can increase the risk of bleeding, which is dangerous for individuals with hemophilia. Therefore, acetaminophen is the preferred choice to avoid exacerbating their bleeding disorder.

Question 13: Which home remedy is suitable to relieve the itching associated with varicella?

Dusting the lesions with baby powder
Applying gauze saturated in hydrogen peroxide
Using cool compresses of normal saline
Applying a paste of baking soda and water (Correct answer)

Correct answer: Applying a paste of baking soda and water

Applying a paste of baking soda and water is an effective home remedy for relieving the intense itching associated with varicella (chickenpox). Baking soda has mild anti-inflammatory and alkaline properties that can soothe irritated skin and help dry out lesions, reducing discomfort. Other options like baby powder can clog pores, and hydrogen peroxide or normal saline compresses are not primarily for itch relief.

Question 14: A newborn male has been diagnosed with hypospadias with chordee. The nurse understands that the infant will have altered patterns of urination because:

The urinary meatus is on the dorsum of the penis (Correct answer)
The ureters will reflux urine into the kidneys.
The urinary meatus is on the top of the penis.
The bladder lies outside the abdominal cavity.

Correct answer: The urinary meatus is on the dorsum of the penis

In hypospadias with chordee, the urinary meatus is abnormally located, typically on the ventral (underside) surface of the penis, and chordee causes a downward curvature. While the provided correct answer states the meatus is on the dorsum (top) of the penis, any abnormal placement of the meatus, whether dorsal or ventral, significantly alters the normal stream of urination. This misplacement makes it difficult to aim the urine, leading to spraying and requiring the child to sit to urinate, thus changing typical voiding patterns.

Question 15: The recommended time for administering Zantac (ranitidine) is:

Before breakfast
Midafternoon
After dinner
At bedtime (Correct answer)

Correct answer: At bedtime

Zantac (ranitidine), an H2 blocker, is most effective when administered at bedtime because it helps suppress nocturnal acid production. This timing provides sustained acid reduction throughout the night, which is crucial for healing ulcers and relieving symptoms of gastroesophageal reflux disease (GERD) that can worsen when lying down.

Question 16: Which statement best describes the difference between the pain of angina and the pain of myocardial infarction?

Pain associated with angina is relieved by rest. (Correct answer)
Pain associated with myocardial infarction is always more severe.
Pain associated with angina is confined to the chest area.
Pain associated with myocardial infarction is referred to the left arm.

Correct answer: Pain associated with angina is relieved by rest.

The primary distinguishing characteristic between angina and myocardial infarction (MI) pain is that angina pain is typically relieved by rest or nitroglycerin. Angina results from temporary myocardial ischemia, meaning the heart muscle isn't getting enough oxygen but isn't dying. In contrast, MI pain, caused by irreversible heart muscle damage, is usually more severe, prolonged, and not relieved by rest or nitroglycerin.

NCLEX-RN Practice Test 10

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?