Module 5 NCLEX Questions

The nurse is caring for a client with thrombocytopenia. Which data should the nurse monitor for related to this condition? Select all that apply. 1.Purpura 2.Ecchymoses 3.Hemoglobin at 14.0 g/dL 4.Thrombocytes at 300,000 mm3 5.Prothrombin time (PT) 14 seconds 6.Platelet count less than 150,000 mm3

1.Purpura 2.Ecchymoses 6.Platelet count less than 150,000 mm3

The nurse reinforces home care instructions to a client diagnosed with systemic lupus erythematosus and instructs the client about methods to manage fatigue. Which statement by the client indicates a need for further teaching? 1."I should take hot baths because they are relaxing." 2."I should sit whenever possible to conserve my energy." 3."I should avoid long periods of rest because it causes joint stiffness." 4."I should do some exercises, such as walking, when I am not fatigued."

1."I should take hot baths because they are relaxing."

The nurse has reviewed activity restrictions with a client who is being discharged following hip surgery and insertion of a femoral head prosthesis. The nurse determines that the client understands the material presented if the client makes which statement? 1."I will use a raised toilet seat." 2."I will bend carefully to put on socks and shoes." 3."I will sit in chairs without arms for better mobility." 4."I will exercise the leg past the point of 90-degree flexion."

1."I will use a raised toilet seat."

The nurse is caring for the client diagnosed with systemic lupus erythematosus (SLE) that is affecting the hematopoietic system. Which data regarding signs and symptoms should the nurse anticipate collecting? Select all that apply. 1.Anemia 2.Alopecia 3.Splenomegaly 4.Discoid erythema 5.Lymphadenopathy 6.Raynaud's phenomenon

1.Anemia 3.Splenomegaly 5.Lymphadenopathy

A client with cancer is receiving chemotherapy and develops thrombocytopenia. Which intervention is a priority in the nursing plan of care? 1.Monitor the client for bleeding. 2.Monitor the client's temperature. 3.Ambulate the client three times daily. 4.Monitor the client for pathological fractures.

1.Monitor the client for bleeding.

A client with a left arm fracture complains of severe, diffuse pain that is unrelieved with pain medication. Based on these findings the nurse should take which action? 1.Notify the registered nurse. 2.Reassess the client in 30 minutes. 3.Check to see whether it is time for more pain medication. 4.Encourage the client to continue with active range-of-motion exercises to the left arm.

1.Notify the registered nurse.

The nurse is caring for a client recently diagnosed with secondary gout. Secondary gout involves hyperuricemia (excessive uric acid in the blood) caused by another disease or factor. Which diseases or factors make clients more at risk for acquiring this condition? Select all that apply. 1.Older clients 2.Obese people 3.Client with liver disease 4.Postmenopausal women 5.Clients from poor economic communities 6.Clients with cardiovascular health problems

1.Older clients 2.Obese people 4.Postmenopausal women 6.Clients with cardiovascular health problems

The nurse is caring for a client in the oncology unit who has developed stomatitis during chemotherapy. The nurse should plan which measure to treat this complication? 1.Rinse the mouth with dilute baking soda or saline solution. 2.Use lemon and glycerin swabs liberally on painful oral lesions. 3.Brush the teeth and use nonwaxed dental floss at least twice a day. 4.Place the client on nothing-by-mouth (NPO) status for 12 hours, and then resume liquids.

1.Rinse the mouth with dilute baking soda or saline solution.

A client has had surgery to repair a fractured left hip. The nurse plans to use which important item when repositioning the client from side to side in the bed? 1.Bed pillow 2.Abductor splint 3.Adductor splint 4.Overhead trapeze

2.Abductor splint

The clinic nurse is teaching a client who has just been diagnosed with osteoporosis about nutritional therapy. Which comment by the client indicates a need for further teaching? 1."I will avoid excessive amounts of alcohol." 2."I'm glad I can still drink as much coffee as I want." 3."I must make sure I include fruits and vegetables in my daily diet." 4."I need to make sure I have adequate amounts of calcium and vitamin D."

2."I'm glad I can still drink as much coffee as I want."

A complete blood cell count is performed on the client with a diagnosis of systemic lupus erythematosus (SLE). The nurse should suspect that which finding will most likely be reported from this blood test? 1.Increased neutrophils 2.Decrease of all cell types 3.Increased red blood cell count 4.Increased white blood cell count

2.Decrease of all cell types

The nurse is caring for a client who has had an open reduction with internal fixation (ORIF) with a posterior approach. The client has been prescribed hip precautions. The nurse plans to implement which activities in the care of the client? Select all that apply. 1.Ensure the client doesn't bend the hips beyond 120 degrees. 2.Ensure the client doesn't sit or stand for long periods of time. 3.Ensure the client engages in rigorous exercise to maintain strength. 4.Ensure the client doesn't cross the legs past the midline of the body. 5.Ensure the client uses assistive/adaptive devices with activities of daily living.

2.Ensure the client doesn't sit or stand for long periods of time. 4.Ensure the client doesn't cross the legs past the midline of the body. 5.Ensure the client uses assistive/adaptive devices with activities of daily living.

A client is admitted to the hospital with vitamin B12 deficiency. When taking the client's history, which symptoms should the nurse expect the client to report? Select all that apply. 1.Craving to eat ice 2.Muscle weakness 3.Dry and brittle hair 4.Difficulty in walking 5.Numbness in hands

2.Muscle weakness 4.Difficulty in walking 5.Numbness in hands

A client with a left arm fracture exhibits loss of sensation in the left fingers, pallor, slow refill, and diminished left radial pulse. The licensed practical nurse (LPN) should take which action? 1.Administer an analgesic. 2.Notify the registered nurse. 3.Check the circulation again in 30 minutes. 4.Provide range-of-motion exercises to the fingers of the left hand.

2.Notify the registered nurse.

The nurse has provided instructions to a client in an arm cast about the signs/symptoms of compartment syndrome. The nurse determines that the client understands the information if the client states to report which early symptom of compartment syndrome? 1.Cold, bluish fingers 2.Numbness and tingling in the fingers 3.Pain that increases when the arm is dependent 4.Pain that is relieved only by an opioid analgesic

2.Numbness and tingling in the fingers

The nurse is caring for a client who has a cast applied to the left lower leg. On data collection, the nurse notes the presence of skin irritation from the edges of a cast. Which nursing intervention is appropriate? 1.Contact the primary health care provider. 2.Petal the cast edges with adhesive tape. 3.Massage the skin at the edges of the cast. 4.Place a small face cloth in the cast around the edges of the cast.

2.Petal the cast edges with adhesive tape.

The nurse is repositioning the client who has returned to the nursing unit following internal fixation of a fractured right hip. How should the nurse plan to position the client? 1.Trochanter roll to prevent abduction while turning 2.Pillow to keep the right leg abducted during turning 3.Pillow to keep the right leg adducted during turning 4.Trochanter roll to prevent external rotation while turning

2.Pillow to keep the right leg abducted during turning

The nurse should monitor for which laboratory result as indicating an adverse reaction in the client who is receiving chemotherapy? 1.Hemoglobin 12.5 g/dL 2.Platelet count 20,000 mm3 3.Blood urea nitrogen (BUN) 20 mg/dL 4.White blood cell count (WBC) 7000 mm3

2.Platelet count 20,000 mm3

A client with lung cancer receiving chemotherapy tells the nurse that the food on the meal tray tastes "funny." Which is the appropriate nursing intervention? 1.Keep the client NPO. 2.Provide oral hygiene care frequently. 3.Administer an antiemetic as prescribed. 4.Consult with the primary health care provider regarding a prescription for parenteral nutrition.

2.Provide oral hygiene care frequently.

The home care nurse is caring for a client who had a below-the-knee amputation of the right leg. What are some teaching points the nurse gives to the client and family? Select all that apply. 1.Apply the bandage in a top-down manner. 2.Use a shrinker stocking or sock to cover the wrapped stump. 3.Rewrap the residual limb once a day with an elastic bandage. 4.Begin residual limb care when sutures or staples are removed. 5.After the limb is healed, it is cleaned each day with the rest of the body during bathing with soap and water. 6.When the staples or sutures are removed, inspect the end of the residual limb every day for signs of inflammation or skin breakdown.

2.Use a shrinker stocking or sock to cover the wrapped stump. 4.Begin residual limb care when sutures or staples are removed. 5.After the limb is healed, it is cleaned each day with the rest of the body during bathing with soap and water. 6.When the staples or sutures are removed, inspect the end of the residual limb every day for signs of inflammation or skin breakdown.

A client is treated in the primary health care provider's office for a sprained ankle. Before sending the client home, the nurse plans to reinforce instructions to the client about which item to avoid in the next 24 hours? 1.Resting the foot 2.Applying an Ace wrap 3.Applying a heating pad 4.Elevating the ankle on a pillow while sitting or lying down

3.Applying a heating pad

The nurse is caring for a client who has developed compartment syndrome from a severely fractured arm. The client asks the nurse how this can happen. How should the nurse explain compartment syndrome? 1.A bone fragment has injured the nerve supply in the area. 2.An injured artery causes impaired arterial perfusion through the compartment. 3.Bleeding and swelling cause increased pressure in an area that cannot expand. 4.The fascia expands with injury, causing pressure on underlying nerves and muscles.

3.Bleeding and swelling cause increased pressure in an area that cannot expand.

The nurse is teaching a client about foods in the diet that could minimize the risk of osteoporosis. The nurse should encourage the client to increase intake of which food? 1.Fish 2.Turkey 3.Cheese 4.Sweet potatoes

3.Cheese

The nurse is assisting in the care of the client diagnosed with systemic lupus erythematosus (SLE). The nurse should most appropriately administer which prescribed medication to manage the condition? 1.Antibiotic 2.Antidiarrheal 3.Corticosteroid 4.Opioid analgesic

3.Corticosteroid

A client has sustained a closed fracture and has just had a cast applied to the affected arm. The client is complaining of intense pain. The nurse has elevated the limb, applied an ice bag, and administered an analgesic, which was ineffective in relieving the pain. The nurse interprets that this pain may be caused by which condition? 1.Infection under the cast 2.The anxiety of the client 3.Impaired tissue perfusion 4.The newness of the fracture

3.Impaired tissue perfusion

The nurse is reviewing the laboratory results of a client with leukemia who has received a regimen of chemotherapy. Which laboratory finding is indicative of the massive cell destruction that occurs with the chemotherapy? 1.Anemia 2.Decreased platelets 3.Increased uric acid level 4.Decreased leukocyte count

3.Increased uric acid level

The nurse is caring for a client with cancer receiving chemotherapy who has developed stomatitis. The nurse plans to give mouth care by using oral care agents and devices that meet which additional criterion? 1.The nurse prefers them. 2.The client requests them. 3.The severity of stomatitis. 4.They are readily available.

3.The severity of stomatitis.

The nurse is collecting data on a client complaining of fatigue, weakness, malaise, muscle pain, joint pain at multiple sites, anorexia, and photosensitivity. Systematic lupus erythematosus (SLE) is suspected. The nurse should further check for which manifestation that is also indicative of the presence of SLE? 1.Emboli 2.Ascites 3.Two hemoglobin S genes 4.Butterfly rash on the cheeks and bridge of the nose

4.Butterfly rash on the cheeks and bridge of the nose

The nurse is caring for a client with osteoarthritis. The nurse collects data, knowing that which is a sign/symptom associated with this disorder? 1.Morning stiffness 2.Positive rheumatoid factor 3.An elevated sedimentation rate 4.Dull aching pain in the affected joints

4.Dull aching pain in the affected joints

The nurse is assigned to care for a client diagnosed with systemic lupus erythematosus (SLE). The nurse should plan care considering which factor regarding this diagnosis? 1.A local rash occurs as a result of allergy. 2.It is a disease caused by overexposure to sunlight. 3.A continuous release of histamine in the body causes the disease. 4.It is an inflammatory disease of collagen contained in connective tissue.

4.It is an inflammatory disease of collagen contained in connective tissue.

The nurse is discussing primary prevention measures to clients regarding osteoporosis. The nurse plans to tell the clients that which is a primary prevention measure? 1.Selecting shoes that have firm nonskid soles 2.Applying nonskid strips on areas that get wet 3.Installing telephones in several rooms of the house 4.Maintaining body weight at or above minimum recommended levels

4.Maintaining body weight at or above minimum recommended levels

The client is suspected of having systemic lupus erythematous (SLE). The nurse monitors the client, knowing that which is one of the initial characteristic signs of SLE? 1.Weight gain 2.Subnormal temperature 3.Elevated red blood cell count 4.Rash on the face across the nose and on the cheeks

4.Rash on the face across the nose and on the cheeks

The nurse is caring for a client who had an above-the-knee amputation 2 days ago. The residual limb was wrapped with an elastic compression bandage that has fallen off. The nurse should immediately perform which action? 1.Apply ice to the site. 2.Call the primary health care provider. 3.Apply a dry sterile dressing and elevates it on one pillow. 4.Rewrap the residual limb with an elastic compression bandage.

4.Rewrap the residual limb with an elastic compression bandage.

A client with type 1 diabetes mellitus has had a left above-the-knee amputation. The nurse carefully inspects the residual limb for which complication because of the history of diabetes? 1.Pain 2.Hemorrhage 3.Edema of the stump 4.Separation of wound edges

4.Separation of wound edges

A primary health care provider has given a prescription for dietary iron supplements to the client with osteoporosis who has an iron deficiency anemia. The nurse suggests that the client do which to enhance compliance with therapy? 1.Decrease fluid intake. 2.Decrease dietary fiber. 3.Chew the tablet thoroughly. 4.Take the medication following a meal.

4.Take the medication following a meal.

Which food sources should the nurse include in the discharge teaching plan of a client with vitamin B12 deficiency anemia? Select all that apply. 1.Eggs 2.Liver 3.Ice cream 4.Red meats 5.Citrus fruits

1.Eggs 2.Liver 4.Red meats

The nurse is reinforcing instructions to a client with osteoporosis regarding appropriate food items to include in the diet. The nurse tells the client that which food item would provide the least amount of calcium? 1.Pork 2.Seafood 3.Sardines 4.Plain yogurt

1.Pork

A nursing instructor asks a nursing student about the risk factors associated with osteoporosis. The instructor determines that the student needs further teaching if the student states that which is an associated risk factor? 1.Postmenopausal age 2.Family history of osteoporosis 3.High-calcium diet consumption 4.Long-term use of corticosteroids

3.High-calcium diet consumption

The nurse witnesses a client sustain a fall and suspects that the client's leg may be fractured. Which action is the priority? 1.Take a set of vital signs. 2.Call the radiology department. 3.Immobilize the leg before moving the client. 4.Reassure the client that everything will be fine.

3.Immobilize the leg before moving the client.

The nurse prepares to care for a client with inflamed joints and plans to use which item to maintain proper positioning for the inflamed joints? 1.Footboards 2.Large pillows 3.Small pillows 4.Soft mattress

3.Small pillows

The nurse determines that the client diagnosed with neutropenia needs further teaching if which statement is made by the client? 1."I will include plenty of fresh fruits in my diet." 2."If I develop a fever over 100° F, I will call my doctor." 3."Petting my dog is fine as long as I wash my hands after doing so." 4."My husband will just have to take over cleaning the cat's litter box."

1."I will include plenty of fresh fruits in my diet."

The nurse is caring for a client with osteoporosis who is being discharged with instructions to take calcium with vitamin D. Which instructions should the nurse give the client about taking this medication? Select all that apply. 1."Take a third of the daily dose at bedtime." 2."Increase fluid intake, unless medically contraindicated." 3."Take the medication with 6 to 8 ounces of water to help dissolve it." 4."You will need to have your blood tested for calcium every month." 5."You can get a slight fever with this medication, so check your temperature every day." 6."After taking this medication for 6 months, you won't have to worry about having any more fractures."

1."Take a third of the daily dose at bedtime." 2."Increase fluid intake, unless medically contraindicated." 3."Take the medication with 6 to 8 ounces of water to help dissolve it."

The nurse is instructing the client with a diagnosis of systemic lupus erythematosus (SLE) about dietary alterations. The nurse should remind the client to avoid which primary foods? Select all that apply. 1.Beef 2.Apples 3.Cheese 4.Chicken 5.Squash

1.Beef 3.Cheese

The nurse is caring for a client who had a total knee replacement. Postoperatively, the nurse monitors for which highest priority assessment? 1.Calf pain 2.Heel breakdown 3.Bladder distention 4.Extremity shortening

1.Calf pain

The nurse reviews the care plan of a client with cancer undergoing chemotherapy. The nurse notes that the client has a concern about her appearance as a result of alopecia. The nurse plans to tell the client which information about hair loss and regrowth to assist the client in coping with this possible change? 1.Facial hair and body hair are generally not affected. 2.Regrown hair may have a different color and texture. 3.Hair loss is usually permanent for many older adult clients. 4.Hair loss usually begins within 5 days of the first treatment.

2.Regrown hair may have a different color and texture.

The nurse is caring for a client with a fractured tibia and fibula. Eight hours after a long leg cast was applied, the client began to report an increase in pain level even after administration of the prescribed dose of opioid analgesic. Which is the initial nursing action? 1.Elevate the casted leg. 2.Contact the primary health care provider. 3.Administer another dose of pain medication. 4.Check the neurovascular status of the toes on the casted leg.

4.Check the neurovascular status of the toes on the casted leg.

The nurse should determine that which are risk factors for systemic lupus erythematous (SLE)? Select all that apply. 1.Male gender 2.Female gender 3.African-American origin 4.Age between 60 to 75 years 5.Being in the childbearing years

2.Female gender 3.African-American origin 5.Being in the childbearing years

A client has just undergone spinal fusion after suffering a herniated lumbar disk. The nurse should avoid which action to maintain client safety after this procedure? 1.Keeping the head of bed flat 2.Having the client use an overhead trapeze 3.Having the client use a logrolling technique for repositioning 4.Placing pillows under the length of the legs

2.Having the client use an overhead trapeze

The nurse is discharging a client with a diagnosis of gout. Which best practice guidelines should the nurse teach the client? Select all that apply. 1.Drink plenty of fluids. 2.Avoid taking diuretics. 3.Avoid taking acetaminophen. 4.Organ meats are allowed on your diet. 5.Avoid excessive physical or emotional stress.

1.Drink plenty of fluids. 2.Avoid taking diuretics. 5.Avoid excessive physical or emotional stress.

The nurse is caring for a client with a fresh application of a plaster leg cast. The nurse should plan to prevent the development of compartment syndrome by which action? 1.Elevating the limb and applying ice to the affected leg 2.Elevating the limb and covering it with bath blankets 3.Keeping the leg horizontal and applying ice to the affected leg 4.Placing the leg in a slightly dependent position and applying ice

1.Elevating the limb and applying ice to the affected leg

The nurse is caring for a client with a tibial fracture who was just diagnosed with acute compartment syndrome (ACS). Which procedure does the nurse anticipate the surgeon will perform? 1.Fasciotomy 2.Arteriotomy 3.Venous thromboectomy 4.External compartment removal

1.Fasciotomy

The nurse is assigned to care for a client admitted with a diagnosis of systemic lupus erythematosus (SLE). The nurse reviews the primary health care provider's prescriptions. Which medication should the nurse expect to be prescribed to aid in long-term control? 1.Aspirin 2.Hydroxychloroquine 3.Dehydroepiandrosterone 4.Nonsteroidal anti-inflammatory drugs

2.Hydroxychloroquine

The nurse is assisting in caring for a client receiving chemotherapy. On review of the morning laboratory results, the nurse notes that the white blood cell count is extremely low, and the client is immediately placed on neutropenic precautions. The client's breakfast tray arrives, and the nurse inspects the meal and prepares to bring the tray into the client's room. Which action should the nurse take before bringing the meal to the client? 1.Remove the coffee from the breakfast tray. 2.Ask the client if she feels like eating at this time. 3.Remove the fresh orange from the breakfast tray. 4.Call the dietary department and ask for disposable utensils.

3.Remove the fresh orange from the breakfast tray.

A client has undergone total hip replacement of the right hip, which was damaged by osteoarthritis. Which action should be included in the postoperative plan of care? 1.Ensure the client receives the daily tablet of enoxaparin. 2.Assist the client in keeping the legs as close together as possible. 3.Remind the client to use a handrail when lowering the hips into a 120-degree flexion. 4.Partial weight bearing on the operative leg is usually permitted 72 hours postoperatively; check surgeon's prescription.

4.Partial weight bearing on the operative leg is usually permitted 72 hours postoperatively; check surgeon's prescription.

A client is receiving chemotherapy that carries a risk of phototoxicity as an adverse effect. Which finding indicates that the client experienced this side effect? 1.Squinting 2.Erythema 3.Petechiae 4.Ecchymoses

2.Erythema

The nurse is reviewing the medical record of the client who is suspected of having systematic lupus erythematosus (SLE). Which sign should the nurse expect to be documented in the record that is most related to this diagnosis? 1.Recurrent emboli 2.Ascites noted in the abdomen 3.Butterfly rash on cheeks and bridge of the nose 4.Presence of two hemoglobin S genes in the blood cell report

3.Butterfly rash on cheeks and bridge of the nose

The nurse is reinforcing instructions to a client with iron deficiency anemia about eating a diet with iron-rich foods. Which food sources should the nurse include in the discharge teaching plan of a client with iron deficiency anemia? Select all that apply. 1.Milk 2.Fish 3.Eggs 4.Liver 5.Cheese

3.Eggs 4.Liver

A client sustained a right proximal fibula and tibia fracture that was casted in a long leg plaster cast. During evening rounds, the nurse notes that the right lower extremity capillary refill is greater than 3 seconds and the toes are edematous and dusky. The client states that the pain medication is not working anymore and that the right foot feels like it is asleep. The nurse analyzes the data and determines that the client's signs/symptoms are indicative of which complication? 1.Fat embolism 2.Venous thrombosis 3.Volkmann's thrombosis 4.Compartment syndrome

4.Compartment syndrome

A client receiving chemotherapy asks the nurse, "What will I do when my hair starts to fall out?" Which action by the nurse is therapeutic? 1.Assist her to express feelings. 2.Offer to help her select a new hairstyle. 3.Ignore the comment and change the subject. 4.Tell her that people don't pay attention to such things anymore.

1.Assist her to express feelings.

The nurse is reinforcing dietary instructions to a client diagnosed with systemic lupus erythematosus. Which dietary items should the nurse most instruct the client to avoid? 1.Steak 2.Turkey 3.Broccoli 4.Cantaloupe

1.Steak

A client with liver cancer who is receiving chemotherapy tells the nurse that some foods on the meal tray taste bitter, especially meats. The nurse should instruct the client to eat which foods instead of meat? Select all that apply. 1.Yogurt 2.Custard 3.Potatoes 4.Cantaloupe 5.Plain potato chips

1.Yogurt 2.Custard

The nurse is caring for a recently admitted client with painful muscle spasms due to a traumatic injury. Besides drug therapy, what are some of the physical measures the nurse expects will be prescribed for this client? Select all that apply. 1.Limiting fluids 2.Whirlpool baths 3.Physical therapy 4.Muscle relaxants 5.Application of hot compresses 6.Immobilization of the affected muscle

2.Whirlpool baths 3.Physical therapy 6.Immobilization of the affected muscle

The nurse is caring for a client with a diagnosis of osteoarthritis. Which actions would be least helpful for the client? 1.Gentle regular exercise 2.A warm bath or shower early in the day 3.Increasingly vigorous and high-impact exercise 4.An individualized program of pain medication administration

3.Increasingly vigorous and high-impact exercise

The nurse is one of several people who witness a vehicle hit a pedestrian at a fairly low speed on a small street. The individual is dazed and tries to get up, and the leg appears fractured. The nurse should plan to perform which action? 1.Try to manually reduce the fracture. 2.Assist the person with getting up and walking to the sidewalk. 3.Leave the person for a few moments to call an ambulance. 4.Stay with the person and encourage the person to remain still.

4.Stay with the person and encourage the person to remain still.