Safe and Effective Care Environment Show A. to a private room so she will not infect other patients and health care workers. B. to a private room so she will not be infected by other patients and health care workers. C. to a semiprivate room so she will have stimulation during her hospitalization. D. to a semiprivate room so she will have the opportunity to express her feelings about her illness. 2. The nurse teaches a group of mothers of toddlers how to prevent accidental poisoning. Which of the following suggestions should the nurse give regarding medications? A. Lock all medications in a cabinet. B. Child proof all the caps to medication bottles. C. Store medications on the highest shelf in a cupboard. D. Place medications in different containers. 3. While inserting a nasogastric tube, the nurse should use which of the following protective measures? A. Gloves, gown, goggles, and surgical cap. B. Sterile gloves, mask, plastic bags, and gown. C. Gloves, gown, mask, and goggles. D. Double gloves, goggles, mask, and surgical cap. 4. A 6-year-old boy is returned to his room following a tonsillectomy. He remains sleepy from the anesthesia but is easily awakened. The nurse should place the child in which of the following positions? A. Sims’. B. Side-lying. C. Supine. D. Prone. 5. A nursing team consists of an RN, an LPN/LVN, and a nursing assistant. The nurse should assign which of the following patients to the LPN/LVN? A. A 72-year-old patient with diabetes who requires a dressing change for a stasis ulcer. B. A 42-year-old patient with cancer of the bone complaining of pain. C. A 55-year-old patient with terminal cancer being transferred to hospice home care. D. A 23-year-old patient with a fracture of the right leg who asks to use the urinal. Health Promotion And Maintenace 6. An 18-year-old woman comes to the physician’s office for a routine prenatal checkup at 34 weeks gestation. Abdominal palpation reveals the fetal position as right occipital anterior (ROA). At which of the following sites would the nurse expect to find the fetal heart tone? A. Below the umbilicus, on the mother’s left side. B. Below the umbilicus, on the mother’s right side. C. Above the umbilicus, on the mother’s left side. D. Above the umbilicus, on the mother’s right side. 7. The nurse in an outpatient clinic is supervising student nurses administering influenza vaccinations. The nurse should question the administration of the vaccine to which of the following clients? A. A 45-year-old male who is allergic to shellfish. B. A 60-year-old female who says she has a sore throat. C. A 66-year-old female who lives in a group home. D. A 70-year-old female with congestive heart failure. 8. The nurse performs a home visit on a client who delivered two days ago. The client states that she is bottle-feeding her infant. The nurse notes white, curd-like patches on the newborn’s oral mucous membranes. The nurse should take which of the following actions? A. Determine the baby’s blood glucose level. B. Suggest that the newborn’s formula be changed. C. Remind the caretaker not to let the infant sleep with the bottle. D. Explain that the newborn will need to receive some medication. 9. A two-month-old infant is brought to the pediatrician’s office for a well-baby visit. During the examination, congenital subluxation of the left hip is suspected. The nurse knows that symptoms of congenital hip dislocation include A. lengthening of the limb on the affected side. B. deformities of the foot and ankle. C. asymmetry of the gluteal and thigh folds. D. plantar flexion of the foot. 10. The nurse teaches a 20-year-old primigravida how to measure the frequency of uterine contractions. The nurse should explain to the patient that the frequency of uterine contractions is determined A. from the beginning of one contraction to the end of the next contraction. B. from the beginning of one contraction to the end of the same contraction. C. by the strength of the contraction at its peak. D. by the number of contractions that occur within a given period of time. Psychosocial Integrity 11. An adolescent male being treated for depression arrives with his family at the Adolescent Day Treatment Center for an initial therapy meeting with the staff. The nurse explains that one of the goals of the family meeting is to encourage the adolescent to: A. trust the nurse who will solve his problem. B. learn to live with anxiety and tension. C. accept responsibility for his actions and choices. D. use the members of the therapeutic milieu to solve his problems. 12. A 23-year-old-woman comes to the emergency room stating that she had been raped. Which of the following statements BEST describes the nurse’s responsibility concerning written consent? A. The nurse should explain the procedure to the patient and ask her to sign the consent form. B. The nurse should verify that the consent form has been signed by the patient and that it is attached to her chart. C. The nurse should tell the physician that the patient agrees to have the examination. D. The nurse should verify that the patient or a family member has signed the consent form. 13. The nurse cares for an elderly patient with moderate hearing loss. The nurse should teach the patient’s family to use which of the following approaches when speaking to the patient? A. Raise your voice until the patient is able to hear you. B. Face the patient and speak quickly using a high voice. C. Face the patient and speak slowly using a slightly lowered voice. D. Use facial expressions and speak as you would normally. 14. A 52-year-old man is admitted to a hospital after sustaining a severe head injury in an automobile accident. When the patient dies, the nurse observes the patient’s wife comforting other family members. Which of the following interpretations of this behavior is MOST justifiable? A. She has already moved through the stages of the grieving process. B. She is repressing anger related to her husband’s death. C. She is experiencing shock and disbelief related to her husband’s death. D. She is demonstrating resolution of her husband’s death. 15. After two weeks of receiving lithium therapy, a patient in the psychiatric unit becomes depressed. Which of the following evaluations of the patient’s behavior by the nurse would be MOST accurate? A. The treatment plan is not effective; the patient requires a larger dose of lithium. B. This is a normal response to lithium therapy; the patient should continue with the current treatment plan. C. This is a normal response to lithium therapy; the patient should be monitored for suicidal behavior. D. The treatment plan is not effective; the patient requires an antidepressant. Physiological Integrity 16. A 65-year-old patient with pneumonia is receiving garamycin (Gentamicin). It would be MOST important for a nurse to monitor which of the following laboratory values in this patient? A. Hemoglobin and hematocrit. B. BUN and creatinine. C. Platelet count and clotting time. D. Sodium and potassium. 17. A 22-year-old man is admitted to the hospital with complaints of fatigue and weight loss. Physical examination reveals pallor and multiple bruises on his arms and legs. The results of the patients tests reveal acute lymphocytic leukemia and thrombocytopenia. Which of the following nursing diagnoses MOST accurately reflects his condition? A. Potential for injury. B. Self-care deficit. C. Potential for self-harm. D. Alteration in comfort. 18. To enhance the percutaneous absorption of nitroglycerine ointment, it would be MOST important for the nurse to select a site that is A. muscular. B. near the heart. C. non-hairy. D. over a bony prominence. 19. A man is admitted to the Telemetry Unit for evaluation of complaints of chest pain. Eight hours after admission, the patient goes into ventricular fibrillation. The physician defibrillates the patient. The nurse understands that the purpose of defibrillation is to: A. increase cardiac contractility and cardiac output. B. cause asystole so the normal pacemaker can recapture. C. reduce cardiac ischemia and acidosis. D. provide energy for depleted myocardial cells. 20. A patient is to receive 3,000 ml of 0.9% NaCl IV in 24 hours. The intravenous set delivers 15 drops per milliliter. The nurse should regulate the flow rate so that the patient receives how many drops of fluid per minute? A. 21 B. 28 C. 31 D. 42 21. A client is scheduled for a myelogram, and the nurse provides a list of instructions to the client regarding preparation for the procedure. Which instructions should the nurse place on the list? Select all that apply. A. Jewelry will need to be removed. B. An informed consent will need to be signed. C. A trained x-ray technician performs the procedure. D. The procedure will take approximately 45 minutes. E. A liquid diet can be consumed on the day of the procedure. F. Solid food intake needs to be restricted only on the day of the procedure. 22. A client with a closed head injury is receiving phenytoin (Dilantin), an anticonvulsant medication. Which of the following would indicate that the client is experiencing side effects related to this medication? Select all that apply. A. Ataxia B. Sedation C. Constipation D. Bleeding gums E. Hyperglycemia F. Decreased platelet count 23. A client with carcinoma of the lung develops the syndrome of inappropriate antidiuretic hormone (SIADH) as a complication of the cancer. The nurse anticipates that which of the following may be prescribed? Select all that apply. A. Radiation B. Chemotherapy C. Increased fluid intake D. Serum sodium blood levels E. Decreased oral sodium intake F. Medication that is antagonistic to antidiuretic hormone (ADH) 24. A client with carcinoma of the lung develops the syndrome of inappropriate antidiuretic hormone (SIADH) as a complication of the cancer. The nurse anticipates that which of the following may be prescribed? Select all that apply. A. Radiation B. Chemotherapy C. Increased fluid intake D. Serum sodium blood levels E. Decreased oral sodium intake F. Medication that is antagonistic to antidiuretic hormone (ADH) 25. The clinic nurse is assisting to perform a focused data collection process on a client who is complaining of symptoms of a cold, a cough, and lung congestion. Which of the following would the nurse include for this type of data collection? Select all that apply. A. Auscultating lung sounds B. Obtaining the client’s temperature C. Checking the strength of peripheral pulses D. Obtaining information about the client’s respirations E. Performing a musculoskeletal and neurological examination F. Asking the client about a family history of any illness or disease Answers and Rationales 1. The correct answer is B. to a private room so she will not infect other patients and health care workers — poses little or no threat to a private room so she will not be infected by other patients and health care workers — CORRECT: protects patient from exogenous bacteria, risk for developing infection from others due to depressed WBC count, alters ability to fight infection to a semiprivate room so she will have stimulation during her hospitalization — should be placed in a room alone to a semiprivate room so she will have the opportunity to express her feelings about her illness — ensure that patient is provided with opportunities to express feelings about illness 2. The correct answer is A. Lock all medications in a cabinet — CORRECT: improper storage most common cause of poisoning; highest incidence in two-year-olds Child proof all the caps to medication bottles — children can open Store medications on the highest shelf in a cupboard — toddlers climb Place medications in different containers — keep in original container 3. The correct answer is C. Gloves, gown, goggles, and surgical cap — surgical caps offer protection to hair but aren’t required. Sterile gloves, mask, plastic bags, and gown — plastic bags provide no direct protection and aren’t part of universal precautions Gloves, gown, mask, and goggles — CORRECT: must use universal precautions on ALL patients; prevent skin and mucous membrane exposure when contact with blood or other body fluids is anticipated Double gloves, goggles, mask, and surgical cap — surgical cap not required; unnecessary to double glove 4. The correct answer is B. Sims’ — on side with top knee flexed and thigh drawn up to chest and lower knee less sharply flexed: used for vaginal or rectal examination Side-lying — CORRECT: most effective to facilitate drainage of secretions from the mouth and pharynx; reduces possibility of airway obstruction. Supine — increased risk for aspiration, would not facilitate drainage of oral secretions Prone — risk for airway obstruction and aspiration, unable to observe the child for signs of bleeding such as increased swallowing 5. The correct answer is A. A 72-year-old patient with diabetes who requires a dressing change for a stasis ulcer — CORRECT: stable patient with an expected outcome A 42-year-old patient with cancer of the bone complaining of pain — requires assessment; RN is the appropriate caregiver A 55-year-old patient with terminal cancer being transferred to hospice home care — requires nursing judgement; RN is the appropriate caregiver A 23-year-old patient with a fracture of the right leg who asks to use the urinal — standard unchanging procedure; assign to the nursing assistant 6. The answer is B. Below the umbilicus, on the mother’s left side — found on right not left side Below the umbilicus, on the mother’s right side — CORRECT: occiput and back are pressing against right side of mother’s abdomen; FHT would be heard below umbilicus on right side Above the umbilicus, on the mother’s left side — found in breech presentation Above the umbilicus, on the mother’s right side — found in breech presentation 7. The correct answer is B. A 45-year-old male who is allergic to shellfish — allergy to eggs is a contraindication A 60-year-old female who says she has a sore throat — CORRECT: vaccine deferred in presence of acute respiratory disease A 66-year-old female who lives in a group home — vaccine deferred only if patient has an active immunization A 70-year-old female with congestive heart failure — no contraindication 8. The correct answer is D. Determine the baby’s blood glucose level — thrush in newborns caused by poor handwashing or exposure to an infected vagina during birth Suggest that the newborn’s formula be changed — not related to thrush Remind the caretaker not to let the infant sleep with the bottle — not related to thrush Explain that the newborn will need to receive some medication — CORRECT: thrush most often treated with nystatin (Mycostatin) 9. The correct answer is C. lengthening of the limb on the affected side — inaccurate deformities of the foot and ankle — inaccurate asymmetry of the gluteal and thigh folds — CORRECT: restricted movement on affected side plantar flexion of the foot — seen with clubfoot 10. The correct answer is D. from the beginning of one contraction to the end of the next contraction — not accurate from the beginning of one contraction to the end of the same contraction — defines duration by the strength of the contraction at its peak — describes intensity by the number of contractions that occur within a given period of time — CORRECT 11. The correct answer is C. trust the nurse who will solve his problem — not realistic learn to live with anxiety and tension — minimizes concerns accept responsibility for his actions and choices — CORRECT use the members of the therapeutic milieu to solve his problems — must do it himself 12. The correct answer is B. The nurse should explain the procedure to the patient and ask her to sign the consent form — Physician should get patient to sign consent The nurse should verify that the consent form has been signed by the patient and that it is attached to her chart — CORRECT The nurse should tell the physician that the patient agrees to have the examination — Physician should explain procedure and get consent form signed The nurse should verify that the patient or a family member has signed the consent form — must be signed by patient unless unable to do 13. The
correct answer is C. Raise your voice until the patient is able to hear you — would result in high tones patient unable to hear Face the patient and speak quickly using a high voice — usually unable to hear high tones Face the patient and speak slowly using a slightly lowered voice — CORRECT: also decrease background noise; speak at a slow pace, use nonverbal cues Use facial expressions and speak as you would normally — nonverbal cues help, but need low tones 14. The correct answer is C. She has already moved through the stages of the grieving process — takes one year She is repressing anger related to her husband’s death — not accurate; second stage: crying, regression She is experiencing shock and disbelief related to her husband’s death — CORRECT: denial first stage; inability to comprehend reality of situation She is demonstrating resolution of her husband’s death — too soon 15. The correct answer is C. The treatment plan is not effective; the patient requires a larger dose of lithium — not accurate This is a normal response to lithium therapy; the patient should continue with the current treatment plan — does not address safety needs This is a normal response to lithium therapy; the patient should be monitored for suicidal behavior — CORRECT: delay of 1-3 weeks before med benefits seen The treatment plan is not effective; the patient requires an antidepressant — normal response 16. The correct answer is B. Hemoglobin and hematocrit — can cause anemia; less common BUN and creatinine — CORRECT: nephrotoxic; will see proteinuria, oliguria, hematuria, thirst, increased BUN, decreased creatine clearance Platelet count and clotting time — do not usually change Sodium and potassium — hypokalemia infrequent problem 17. The correct answer is A. Potential for injury — CORRECT: low platelet increases risk of bleeding from even minor injuries. Safety measures: shave with an electric razor, use soft tooth brush, avoid SQ or IM meds and invasive procedures (urinary drainage catheter or a nasogastric tube), side-rails up, remove sharp objects, frequently assess for signs of bleeding, bruising, hemorrhage. Self-care deficit — may feel weak, doesn’t address condition Potential for self-harm — implies risk for purposeful self-injury, not given any info, assumption Alteration in comfort — patient is not comfortable, and comfort measures would address problem 18. The correct answer is C. muscular — not most important near the heart — not most important non-hairy — CORRECT: skin site free of hair will increase absorption; avoid distal part of extremities due to less than maximal absorption over a bony prominence — most important is that the site be non-hairy 19. The correct
answer is B. increase cardiac contractility and cardiac output — inaccurate cause asystole so the normal pacemaker can recapture — CORRECT: allows SA node to resume as pacer of heart activity reduce cardiac ischemia and acidosis — inaccurate provide energy for depleted myocardial cells — inaccurate 20. The correct answer is C. 21 — inaccurate 28 — inaccurate 31 — CORRECT: 3,000 x 15 divided by 24 x 60 42 — inaccurate 21. The correct answer are A, B, and D. 22.The correct answer are C,
D, E, and F. 23.The
correct answer are A, B, D, and F. 24. The correct answer are A, B, D and F. 25.The correct answer are A, B, and D. NCLEX Quiz Series - 5 What is the nursing diagnosis with acute lymphocytic leukemia and thrombocytopenia?Based on the assessment data, major nursing diagnoses for the patient with ALL may include: Risk for infection related to overproduction of immature WBCs. Risk for impaired skin integrity related to toxic effects of chemotherapy, alteration in nutrition, and impaired immobility.
What are some nursing diagnosis for leukemia?Here are five (5) nursing care plans (NCP) and nursing diagnosis for patients with leukemia:. Risk for Infection.. Risk for Deficient Fluid Volume.. Acute Pain.. Activity Intolerance.. Deficient Knowledge.. Other Possible Nursing Care Plans.. What are three differential diagnoses for acute lymphocytic leukemia?The following are possible differential diagnosis for ALL: Acute myelocytic leukemia. Acute anemia. Juvenile Rheumatoid Arthritis.
How does acute lymphoblastic leukemia cause thrombocytopenia?Thrombocytopenia may develop in patients with acute lymphoblastic leukemia (ALL) due to myelosuppression of chemotherapy or relapse.
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