NCLEX QUESTIONS

• The nurse is monitoring a child for bleeding after surgery for removal of a brain tumor. The nurse checks the head dressing for the presence of blood and notes a colorless drainage on the back of the dressing. Which intervention should the nurse perform immediately?

  
  

  1. Reinforce the dressing.

  2. Notify the health care provider (HCP).

  3. Document the findings and continue to monitor.

  4. Circle the area of drainage and continue to monitor.

  2. Notify the health care provider (HCP).
• A child undergoes surgical removal of a brain tumor. During the postoperative period, the nurse notes that the child is restless, the pulse rate is elevated, and the blood pressure has decreased significantly from the baseline value. The nurse suspects that the child is in shock. Which is the most appropriate nursing action?

  
  

  1. Place the child in a supine position.

  2. Notify the health care provider (HCP).

  3. Place the child in Trendelenburg position.

  4. Increase the flow rate of the intravenous fluids

  2. Notify the health care provider (HCP).
• The mother of a 4-year-old child tells the pediatric nurse that the child's abdomen seems to be swollen. During further assessment, the mother tells the nurse that the child is eating well and that the activity level of the child is unchanged. The nurse, suspecting the possibility of Wilms' tumor, should avoid which during the physical assessment?

  
  

  1. Palpating the abdomen for a mass

  2. Assessing the urine for the presence of hematuria

  3. Monitoring the temperature for the presence of fever

  4. Monitoring the blood pressure for the presence of hypertension

  1. Palpating the abdomen for a mass
• The nurse provides a teaching session to the nursing staff regarding osteosarcoma. Which statement by a member of the nursing staff indicates a need for information?

  
  

  1. "The femur is the most common site of this sarcoma."

  2. "The child does not experience pain at the primary tumor site."

  3. "Limping, if a weight-bearing limb is affected, is a clinical manifestation."

  4. "The symptoms of the disease in the early stage are almost always attributed to normal growing pains."

  2. "The child does not experience pain at the primary tumor site."
• The nurse analyzes the laboratory values of a child with leukemia who is receiving chemotherapy. The nurse notes that the platelet count is 19,500 mm3 (19.5 Â 109 /L). On the basis of this laboratory result, which intervention should the nurse include in the plan of care?

  
  

  1. Initiate bleeding precautions.

  2. Monitor closely for signs of infection.

  3. Monitor the temperature every 4 hours.

  4. Initiate protective isolation precautions.

  1. Initiate bleeding precautions.
• The nurse is monitoring a 3-year-old child for signs and symptoms of increased intracranial pressure (ICP) after a craniotomy. The nurse plans to monitor for which early sign or symptom of increased ICP?

  
  

  1. Vomiting

  2. Bulging anterior fontanel

  3. Increasing head circumference

  4. Complaints of a frontal headache

  1. Vomiting
• A 4-year-old child is admitted to the hospital for abdominal pain. The mother reports that the child has been pale and excessively tired and is bruising easily. On physical examination, lymphadenopathy and hepatosplenomegaly are noted. Diagnostic studies are being performed because acute lymphocytic leukemia is suspected. The nurse determines that which laboratory result confirms the diagnosis?

  
  

  1. Lumbar puncture showing no blast cells

  2. Bone marrow biopsy showing blast cells

  3. Platelet count of 350,000 mm3 (350 Â 109 /L) 4. White blood cell count 4500 mm3 (4.5Â 109 /L)

  2. Bone marrow biopsy showing blast cells
• A 6-year-old child with leukemia is hospitalized and is receiving combination chemotherapy. Laboratory results indicate that the child is neutropenic, and protective isolation procedures are initiated. The grandmother of the child visits and brings a fresh bouquet of flowers picked from her garden, and asks the nurse for a vase for the flowers. Which response should the nurse provide to the grandmother?

  
  

  1. "I have a vase in the utility room, and I will get it for you."

  2. "I will get the vase and wash it well before you put the flowers in it."

  3. "The flowers from your garden are beautiful, but should not be placed in the child's room at this time."

  4. "When you bring the flowers into the room, place them on the bedside stand as far away from the child as possible."

  3. "The flowers from your garden are beautiful, but should not be placed in the child's room at this time."
• A diagnosis of Hodgkin's disease is suspected in a 12-year-old child. Several diagnostic studies are performed to determine the presence of this disease. Which diagnostic test result will confirm the diagnosis of Hodgkin's disease?

  
  

  1. Elevated vanillylmandelic acid urinary levels 2. The presence of blast cells in the bone marrow

  3. The presence of Epstein-Barr virus in the blood

  4. The presence of Reed-Sternberg cells in the lymph nodes

  4. The presence of Reed-Sternberg cells in the lymph nodes
• Which specific nursing interventions are implemented in the care of a child with leukemia who is at risk for infection? Select all that apply.

  
  

  1. Maintain the child in a semiprivate room.

  2. Reduce exposure to environmental organisms.

  3. Use strict aseptic technique for all procedures.

  4. Ensure that anyone entering the child's room wears a mask.

  5. Apply firm pressure to a needle-stick area for at least 10 minutes.

  2. Reduce exposure to environmental organisms.

  3. Use strict aseptic technique for all procedures.

  4. Ensure that anyone entering the child's room wears a mask.
• The nurse is performing an assessment on a 10- year-old child suspected to have Hodgkin's disease. Which assessment findings are specifically characteristic of this disease? Select all that apply.

  
  

  1. Abdominal pain

  2. Fever and malaise

  3. Anorexia and weight loss 4. Painful, enlarged inguinal lymph nodes

  5. Painless, firm, and movable adenopathy in the cervical area


  1. Abdominal pain

  5. Painless, firm, and movable adenopathy in the cervical area
• The nurse is reviewing the laboratory results of a client diagnosed with multiple myeloma. Which would the nurse expect to note specifically in this disorder?

  
  

  1. Increased calcium level

  2. Increased white blood cells

  3. Decreased blood urea nitrogen level

  4. Decreased number of plasma cells in the bone marrow

  1. Increased calcium level
• The nurse is creating a plan of care for the client with multiple myeloma and includes which priority intervention in the plan?

  
  

  1. Encouraging fluids

  2. Providing frequent oral care

  3. Coughing and deep breathing

  4. Monitoring the red blood cell count

  1. Encouraging fluidsSee an expert-written answer!We have an expert-written solution to this problem!
• When caring for a client with an internal radiation implant, the nurse should observe which principles? Select all that apply.

  
  

  1. Limiting the time with the client to 1 hour per shift.

  2. Keeping pregnant women out of the client's room.

  3. Placing the client in a private room with a private bath.

  4. Wearing a lead shield when providing direct client care.

  5. Removing the dosimeter film badge when entering the client's room.6. Allowing individuals younger than 16 years old in the room as long as they are 6 feet away from the client.


  2. Keeping pregnant women out of the client's room.

  3. Placing the client in a private room with a private bath.

  4. Wearing a lead shield when providing direct client care
• While giving care to a client with an internal cervical radiation implant, the nurse finds the implant in the bed. The nurse should take which initial action?

  
  

  1. Call the health care provider (HCP).

  2. Reinsert the implant into the vagina.

  3. Pick up the implant with gloved hands and flush it down the toilet.

  4. Pick up the implant with long-handled forceps and place it in a lead container.

  4. Pick up the implant with long-handled forceps and place it in a lead container.See an expert-written answer!We have an expert-written solution to this problem!
• The nurse should plan to implement which intervention in the care of a client experiencing neutropenia as a result of chemotherapy?

  
  

  1. Restrict all visitors.

  2. Restrict fluid intake.

  3. Teach the client and family about the need for hand hygiene.

  4. Insert an indwelling urinary catheter to prevent skin breakdown.

  3. Teach the client and family about the need for hand hygiene.
• The home health care nurse is caring for a client with cancer who is complaining of acute pain. The most appropriate determination of the client's pain should include which assessment?

  
  

  1. The client's pain rating

  2. Nonverbal cues from the client

  3. The nurse's impression of the client's pain

  4. Pain relief after appropriate nursing intervention

  1. The client's pain rating
• The nurse is caring for a client who is postoperative following a pelvic exenteration and the health care provider changes the client's diet from NPO (nothing by mouth) status to clear liquids. The nurse should check which priority item before administering the diet?

  
  

  1. Bowel sounds

  2. Ability to ambulate

  3. Incision appearance

  4. Urine specific gravity


  1. Bowel soundsSee an expert-written answer!We have an expert-written solution to this problem!
• Aclient is admitted to the hospital with a suspected diagnosis of Hodgkin's disease. Which assessment finding would the nurse expect to note specifically in the client?

  
  

  1. Fatigue

  2. Weakness

  3. Weight gain

  4. Enlarged lymph nodes

  4. Enlarged lymph nodesSee an expert-written answer!We have an expert-written solution to this problem!
• During the admission assessment of a client with advanced ovarian cancer, the nurse recognizes which manifestation as typical of the disease?

  
  

  1. Diarrhea

  2. Hypermenorrhea

  3. Abnormal bleeding

  4. Abdominal distention

  4. Abdominal distention
• The nurse is caring for a client with lung cancer and bone metastasis. What signs and symptoms would the nurse recognize as indications of a possible oncological emergency? Select all that apply.

  
  

  1. Facial edema in the morning

  2. Weight loss of 20 lb (9 kg) in 1 month

  3. Serum calcium level of12 mg/dL(3.0 mmol/L) 4. Serum sodium level of 136 mg/dL (136 mmol/L)

  5. Serum potassium level of 3.4 mg/dL (3.4 mmol/L)

  6. Numbness and tingling of the lower extremities


  1. Facial edema in the morning

  
  

  3. Serum calcium level of12 mg/dL(3.0 mmol/L) 4. Serum sodium level of 136 mg/dL (136 mmol/L)

  
  

  6. Numbness and tingling of the lower extremities
• A client who has been receiving radiation therapy for bladder cancer tells the nurse that it feels as if she is voiding through the vagina. The nurse interprets that the client may be experiencing which condition?

  
  

  1. Rupture of the bladder

  2. The development of a vesicovaginal fistula

  3. Extreme stress caused by the diagnosis of cancer

  4. Altered perineal sensation as a side effect of radiation therapy

  2. The development of a vesicovaginal fistula
• The nurse is instructing a client to perform a testicular self-examination (TSE). The nurse should provide the client with which information about the procedure?

  
  

  1. To examine the testicles while lying down

  2. That the best time for the examination is after a shower

  3. To gently feel the testicle with 1 finger to feel for a growth

  4. That TSEs should be done at least every 6 months

  2. That the best time for the examination is after a shower
• The nurse is conducting a history and monitoring laboratory values on a client with multiple myeloma. What assessment findings should the nurse expect to note? Select all that apply.

  
  

  1. Pathological fracture

  2. Urinalysis positive for nitrites

  3. Hemoglobin level of 15.5 g/dL (155 mmol/L) 4. Calcium level of 8.6 mg/dL (2.15 mmol/L)

  5. Serum creatinine level of 2.0 mg/dL (176.6 mcmol/L)

  1. Pathological fracture

  
  

  2. Urinalysis positive for nitrites

  
  

  5. Serum creatinine level of 2.0 mg/dL (176.6 mcmol/L)
• A gastrectomy is performed on a client with gastric cancer. In the immediate postoperative period, the nurse notes bloody drainage from the nasogastric tube. The nurse should take which most appropriate action?

  
  

  1. Measure abdominal girth.

  2. Irrigate the nasogastric tube.

  3. Continue to monitor the drainage.

  4. Notify the health care provider (HCP).

  3. Continue to monitor the drainage.
• The nurse is teaching a client about the risk factors associated with colorectal cancer. The nurse determines that further teaching is necessary related to colorectal cancer if the client identifies which item as an associated risk factor?

  
  

  1. Age younger than 50 years

  2. History of colorectal polyps

  3. Family history of colorectal cancer

  4. Chronic inflammatory bowel disease

  1. Age younger than 50 years
• The nurse is assessing the perineal wound in a client who has returned from the operating room following an abdominal perineal resection and notes serosanguineous drainage from the wound. Which nursing intervention is most appropriate?

  
  

  1. Clamp the surgical drain.

  2. Change the dressing as prescribed.

  3. Notify the health care provider (HCP).

  4. Remove and replace the perineal packing.

  2. Change the dressing as prescribed.
• The nurse is assessing the colostomy of a client who has had an abdominal perineal resection for a bowel tumor. Which assessment finding indicates that the colostomy is beginning to function?

  
  

  1. The passage of flatus

  2. Absent bowel sounds

  3. The client's ability to tolerate food

  4. Bloody drainage from the colostomy

  1. The passage of flatus
• The nurse is reviewing the history of a client with bladder cancer. The nurse expects to note documentation of which most common sign or symptom of this type of cancer?

  
  

  1. Dysuria

  2. Hematuria

  3. Urgency on urination

  4. Frequency of urination

  2. HematuriaSee an expert-written answer!We have an expert-written solution to this problem!
• The nurse is assessing a client who has a new ureterostomy. Which statement by the client indicates the need for more education about urinary stoma care?

  
  

  1. "I change my pouch every week."

  2. "I change the appliance in the morning."

  3. "I empty the urinary collection bag when it is two-thirds full."

  4. "When I'm in the shower I direct the flow of water away from my stoma."

  3. "I empty the urinary collection bag when it is two-thirds full."
• A client with carcinoma of the lung develops syndrome of inappropriate antidiuretic hormone (SIADH) as a complication of the cancer. The nurse anticipates that the health care provider will request which prescriptions? Select all that apply.

  
  

  1. Radiation

  2. Chemotherapy

  3. Increased fluid intake

  4. Decreased oral sodium intake

  5. Serum sodium level determination

  6. Medication that is antagonistic to antidiuretic hormone

  1. Radiation

  
  

  2. Chemotherapy

  
  

  5. Serum sodium level determination

  
  

  6. Medication that is antagonistic to antidiuretic hormoneSee an expert-written answer!We have an expert-written solution to this problem!
• The nurse is monitoring a client for signs and symptoms related to superior vena cava syndrome. Which is an early sign of this oncological emergency?

  
  

  1. Cyanosis

  2. Arm edema

  3. Periorbital edema

  4. Mental status changes

  3. Periorbital edema
• The nurse manager is teaching the nursing staff about signs and symptoms related to hypercalcemia in a client with metastatic prostate cancer, and tells the staff that which is a late sign or symptom of this oncological emergency?

  
  

  1. Headache

  2. Dysphagia

  3. Constipation

  4. Electrocardiographic changes

  4. Electrocardiographic changes
• As part of chemotherapy education, the nurse teaches a female client about the risk for bleeding and self-care during the period of greatest bone marrow suppression (the nadir). The nurse understands that further teaching is needed if the client makes which statement?

  
  

  1. "I should avoid blowing my nose."

  2. "I may need a platelet transfusion if my platelet count is too low."

  3. "I'm going to take aspirin for my headache as soon as I get home."

  4. "I will count the number of pads and tampons I use when menstruating."

  3. "I'm going to take aspirin for my headache as soon as I get home."
• The community health nurse is instructing a group of young female clients about breast self examination. The nurse should instruct the clients to perform the examination at which time?

  
  

  1. At the onset of menstruation

  2. Every month during ovulation

  3. Weekly at the same time of day

  4. 1 week after menstruation begins


  4. 1 week after menstruation begins
• A client is diagnosed as having a bowel tumor. The nurse should monitor the client for which complications of this type of tumor? Select all that apply.

  
  

  1. Flatulence

  2. Peritonitis

  3. Hemorrhage

  4. Fistula formation

  5. Bowel perforation

  6. Lactose intolerance

  2. Peritonitis

  3. Hemorrhage

  4. Fistula formation

  5. Bowel perforation
• The nurse is caring for a client following a mastectomy. Which nursing intervention would assist in preventing lymphedema of the affected arm?

  
  

  1. Placing cool compresses on the affected arm

  2. Elevating the affected arm on a pillow above heart level

  3. Avoiding arm exercises in the immediate postoperative period

  4. Maintaining an intravenous site below the antecubital area on the affected side

  2. Elevating the affected arm on a pillow above heart level
• Skin reactions are common in radiation therapy. Nursing responsibilities on promoting skin integrity should be promoted apart from:

  
  

  A. Avoiding the use of ointments, powders and lotion to the area

  B. Using soft cotton fabrics for clothing

  C. Washing the area with a bar of scented soap and water and patting it dry not rubbing it

  D. Avoiding direct sunshine or cold.

  C. Washing the area with a bar of scented soap and water and patting it dry not rubbing it
• Nausea and vomiting is an expected side effect of chemotherapeutic drug use. Which of the following drugs should be administered to a client on chemotherapy to prevent nausea and vomiting?

  
  

  A. Myleran (busulfan)

  B. Chemet (succimer)

  C. Arimidex (anastrozole)

  D. Metozol (metoclopramide)

  D. Metozol (metoclopramide)
• Radiation protection is very important to implement when performing nursing procedures. When the nurse is not performing any nursing procedures what distance should be maintained from the client?

  
  

  A. 1 feet

  B. 2 feet

  C. 2.5 feet

  D. 3 feet

  D. 3 feet