NCLEX-RN EXAM PACK SET 8 75
QUESTIONS & ANSWERS UPDATED EXAM
|QUESTIONS WITH CORRECT DETAILED
ANSWERS (VERIFIED ANSWERS) |A+
GRADED
1. 1. Question
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A 21-year-old male with Hodgkin’s lymphoma is a senior at the
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local university. He is engaged to be married and is to begin a
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new job upon graduation. Which of the following diagnoses
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wouldbe a priority for this client?
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o A. Sexual dysfunction related to radiation therapy
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o B. Anticipatory grieving related to terminal illness
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o C. Tissue integrity related to prolonged bed rest
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o D. Fatigue related to chemotherapy
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Correct Answer: A. Sexual dysfunction related to
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radiationtherapy
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Radiation therapy often causes sterility in male clients and would
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be of primary importance to this client. The psychosocial needs
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ofthe client are important to address in light of the age and
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life choices. Hodgkin’s disease, however, has a good prognosis
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when diagnosed early. Know the importance of sex to individual,
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partner, and patient’s motivation for change. Because
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lymphomas often affect the relatively young who are in their
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productive years, these people may be affected more by these
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problems and may be less knowledgeable about the
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possibilitiesof change.
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o Option B: Grieving may not be an appropriate
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diagnosis since the client would be experiencing
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new milestones in his life despite his condition. Let
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the patient describe the problem in own words.
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Provides amore accurate picture of patient
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experience with which to develop a plan of care.
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, o Option C: Option B is not applicable since the client
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isnot on bed rest. Encourage the patient to share
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thoughts and concerns with his partner and to clarify
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values and impact of condition on relationship. Helps
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the couple begin to deal with issues that can
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strengthen or weaken the relationship.
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o Option D: Fatigue may occur during chemotherapy, V V V V V V
but it is not the priority diagnosis. Identify pre-
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existingand current stress factors that may be V V V V V V V
affecting the relationship. The patient may be
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concerned about other issues, such as job, financial,
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and illness-related problems.
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• 2. Question
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A client has autoimmune thrombocytopenic purpura. To
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determine the client’s response to treatment, the nurse would
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monitor:
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o A. Platelet count
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o B. White blood cell count
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o C. Potassium levels
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o D. Partial prothrombin time (PTT)
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Correct Answer: A. Platelet count
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Clients with autoimmune thrombocytopenic purpura (ATP) have
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low platelet counts, making answer A the correct answer. The
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laboratory tests will show low platelet count, usually
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<40×10^9/L for over three months. Blood film shows large
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platelets and tiny platelet fragments. Bone marrow examination
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shows an increased number of megakaryocytes.
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o Option B: Often associated with the CBC is a
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differential, which refers to the relative amounts of
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white blood cell types (i.e., neutrophil, lymphocyte,
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eosinophil, etc.) as a percentage of the total number
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of WBCs. Of note, if a subtype of white blood cells
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seems to be elevated based on the differential, the
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actual value of the type of white blood cells should
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be V
, calculated by multiplying the percentage listed on V V V V V V
thedifferential by the total number of white blood
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cells. V
o Option C: Potassium disorders are related to cardiac
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arrhythmias. Hypokalemia occurs when serum
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potassium levels under 3.6 mmol/L—weakness,
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fatigue, and muscle twitching present in
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hypokalemia.Hyperkalemia occurs when the serum
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potassium levels above 5.5 mmol/L, which can result
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in arrhythmias. Muscle cramps, muscle weakness,
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rhabdomyolysis, myoglobinuria are presenting signs
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and symptoms in hyperkalemia.
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o Option D: Patients with a propensity for bleeding V V V V V V V
should undergo testing to determine the presence of
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a clotting disorder. For patients with deficiencies or
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defects of the intrinsic clotting cascade, the PTT will
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beelevated. Normal PTT values can vary between
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laboratories but 25 to 35 seconds is considered
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normal. V
• 3. Question
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The home health nurse is visiting a client with autoimmune
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thrombocytopenic purpura (ATP). The client’s platelet count
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currently is 80, it will be most important to teach the client
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andfamily about:
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o A. Bleeding precautions
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o B. Prevention of falls
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o C. Oxygen therapy
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o D. Conservation of energy
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Correct Answer: A. Bleeding precautions
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The normal platelet count is 120,000–400, Bleeding occurs in
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clients with low platelets. The priority is to prevent and minimize
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bleeding. Review laboratory results for coagulation status as
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appropriate: platelet count, prothrombin time/international
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normalized ratio (PT/INR), activated partial thromboplastin time
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(aPTT), fibrinogen, bleeding time, fibrin degradation products,
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vitamin K, activated coagulation time (ACT); and educate the at-
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, risk patient and caregivers about precautionary measures to
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prevent tissue trauma or disruption of the normal clotting
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Vmechanisms.
o Option B: Thoroughly conform patient to V V V V V
surroundings; put call light within reach and teach
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howto call for assistance; respond to call light
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immediately; avoid use of restraints; obtain a
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physician’s order if restraints are needed; and
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eliminate or drop all possible hazards in the room such
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as razors, medications, and matches.
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o Option C: Option C is important, but platelets do not
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carry oxygen. Wash hands and teach patient and SO
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towash hands before contact with patients and
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between procedures with the patient; encourage fluid
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intake of 2,000 to 3,000 mL of water per day, unless
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contraindicated. V
o Option D: Option D is of lesser priority and is in this
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instance. Recommend the use of soft-bristled
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toothbrushes and stool softeners to protect mucous
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membranes; and if infection occurs, teach the patient
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to take antibiotics as prescribed; instruct the patient
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totake the full course of antibiotics even if symptoms
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improve or disappear.
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• 4. Question V
A client with a pituitary tumor has had transsphenoidal
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hypophysectomy. Which of the following interventions would
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beappropriate for this client?
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o A. Place the client in Trendelenburg position for postural
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drainage
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o B. Encourage coughing and deep breathing every 2
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hours
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o C. Elevate the head of the bed 30°
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o D. Encourage the Valsalva maneuver for bowel
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movements
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Correct Answer: C. Elevate the head of the bed 30°
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