NCLEX-RN
NCLEX RN Practice Questions Quizlet
1. A patient with leukemia is receiving chemotherapy that is known to depress bone marrow. A CBC (complete blood count) reveals a platelet count of 25,000/microliter. Which of the following actions related specifically to the platelet count should be included in the nursing care plan?
- A. Monitor for fever every 4 hours.
- B. Require visitors to wear respiratory masks and protective clothing.
- C. Consider transfusion of packed red blood cells.
- D. Check for signs of bleeding, including examination of urine and stool for blood.
Correct answer: Check for signs of bleeding, including examination of urine and stool for blood.
Rationale: A platelet count of 25,000/microliter indicates severe thrombocytopenia, which increases the risk of bleeding. It is crucial to initiate bleeding precautions, including regularly checking for signs of bleeding such as examining urine and stool for blood. Monitoring for fever every 4 hours (Choice A) should be included for neutropenic precautions, not specifically related to platelet count. Requiring visitors to wear respiratory masks and protective clothing (Choice B) is more relevant for patients with airborne precautions. Considering transfusion of packed red blood cells (Choice C) is not indicated for low platelet count but is more appropriate for managing anemia or low hemoglobin levels.
2. A child weighing 30 kg arrives at the clinic with diffuse itching as the result of an allergic reaction to an insect bite. Diphenhydramine (Benadryl) 25 mg 3 times a day is prescribed. The correct pediatric dose is 5 mg/kg/day. Which of the following best describes the prescribed drug dose?
- A. It is the correct dose
- B. The dose is too low
- C. The dose is too high
- D. The dose should be increased or decreased, depending on the symptoms
Correct answer: The dose is too low
Rationale: The correct pediatric dose of diphenhydramine is 5 mg/kg/day. This child weighs 30 kg, so the calculated dose would be 5 mg/kg x 30 kg = 150 mg/day. Since the prescription is for 25 mg 3 times a day, the total daily dose is 25 mg x 3 = 75 mg/day, which is lower than the calculated dose of 150 mg/day. Therefore, the prescribed dose of 25 mg 3 times a day is too low for this child. The dose should be adjusted to meet the correct dosage of 150 mg/day, which would be 50 mg 3 times a day. It is important not to titrate the dosage based on symptoms without consulting a physician, as this can lead to inappropriate medication administration.
3. A patient asks a nurse administering blood how long red blood cells live in the body. What is the correct response?
- A. The life span of RBC is 45 days
- B. The life span of RBC is 60 days
- C. The life span of RBC is 90 days
- D. The life span of RBC is 120 days
Correct answer: The life span of RBC is 120 days
Rationale: The correct answer is that red blood cells have a lifespan of 120 days in the body. This allows for efficient oxygen transport throughout the circulatory system. Choices A, B, and C are incorrect because the lifespan of red blood cells is actually 120 days. Understanding the lifespan of red blood cells is crucial in assessing various conditions related to blood cell production and turnover.
4. During an assessment of a client with cardiomyopathy, the nurse finds that the systolic blood pressure has decreased from 145 to 110 mm Hg and the heart rate has risen from 72 to 96 beats per minute, and the client complains of periodic dizzy spells. The nurse instructs the client to:
- A. Increase fluids that are high in protein
- B. Restrict fluids
- C. Force fluids and reassess blood pressure
- D. Limit fluids to non-caffeine beverages
Correct answer: Force fluids and reassess blood pressure
Rationale: In this scenario, the client with cardiomyopathy is exhibiting signs of orthostatic hypotension, which is characterized by a significant drop in systolic blood pressure (>15 mm Hg) and an increase in heart rate (>15%), along with dizziness. These symptoms suggest volume depletion, inadequate vasoconstrictor mechanisms, and autonomic insufficiency. The appropriate nursing intervention in this case is to force fluids and reassess blood pressure to address the underlying issue of volume depletion and improve hemodynamic stability. Choices A, B, and D are incorrect because increasing fluids high in protein, restricting fluids, or limiting fluids to non-caffeine beverages are not appropriate actions for a client experiencing orthostatic hypotension and signs of volume depletion.
5. A patient is admitted to the same-day surgery unit for a liver biopsy. Which of the following laboratory tests assesses coagulation? Select one that doesn't apply.
- A. Partial thromboplastin time
- B. Prothrombin time
- C. Platelet count
- D. Hemoglobin
Correct answer: D: Hemoglobin
Rationale: The correct answer is 'Hemoglobin.' Hemoglobin levels are not indicative of coagulation status but are important for assessing oxygen-carrying capacity. Choices A, B, and C are all laboratory tests that assess coagulation. Partial thromboplastin time (PTT) and prothrombin time (PT) evaluate different aspects of the coagulation cascade, while platelet count is essential for assessing primary hemostasis. Therefore, in the context of evaluating coagulation, hemoglobin is not the appropriate choice.
Similar Questions
Access More Features
NCLEX RN Basic
$69.99/ 30 days
- 5,000 Questions with answers
- Comprehensive NCLEX coverage
- 30 days access @ $69.99
NCLEX RN Premium
$149.99/ 90 days
- 5,000 Questions with answers
- Comprehensive NCLEX coverage
- 30 days access @ $149.99