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Correct Answer: A. Sexual dysfunction related to radiation therapy Radiation therapy often causes sterility in male clients and would be of primary importance to this client. The psychosocial needs of the client are important to address in light of the age and life choices. Hodgkin’s disease, however, has a good prognosis when diagnosed early. Know the importance of sex to individual, partner, and patient’s motivation for change. Because lymphomas often affect the relatively young who are in their productive years, these people may be affected more by these problems and may be less knowledgeable about the possibilities of change. o Option B: Grieving may not be an appropriate diagnosis since the client would be experiencing new milestones in his life despite his condition. Let the patient describe the problem in own words.
NCLEX-RN Exam Pack Set 8 (75 Questions &
Answers, Latest Update 2025)
1. 1. Question
A 21-year-old male with Hodgkin’s lymphoma is a senior at the local university. He is engaged to be married and is to begin a new job upon graduation. Which of the following diagnoses would be a priority for this client? o A. Sexual dysfunction related to radiation therapy o B. Anticipatory grieving related to terminal illness o C. Tissue integrity related to prolonged bed rest o D. Fatigue related to chemotherapy
o Option B: Often associated with the CBC is a differential, which refers t Correct Answer: A. Platelet count Clients with autoimmune thrombocytopenic purpura (ATP) have low platelet counts o Option C: Option B is not applicable since the client is not on bed rest. Encourage the patient to share thoughts and concerns with his partner and to clarify values and impact of condition on relationship. Helps the couple begin to deal with issues that can strengthen or weaken the relationship. o Option D: Fatigue may occur during chemotherapy, but it is not the priority diagnosis. Identify pre- existing and current stress factors that may be affecting the relationship. The patient may be
- 2. Question A client has autoimmune thrombocytopenic purpura. To determine the client’s response to treatment, the nurse would monitor: o A. Platelet count o B. White blood cell count o C. Potassium levels o D. Partial prothrombin time (PTT)
risk patient and caregivers about precautionary measures to prevent tissue trauma or disruption of the normal clotting mechanisms. o Option B: Thoroughly conform patient to surroundings; put call light within reach and teach how to call for assistance; respond to call light immediately; avoid use of restraints; obtain a physician’s order if restraints are needed; and eliminate or drop all possible hazards in the room such as razors, medications, and matches. o Option C: Option C is important, but platelets do not carry oxygen. Wash hands and teach patient and SO to wash hands before contact with patients and between procedures with the patient; encourage fluid intake of 2,000 to 3,000 mL of water per day, unless contraindicated. o Option D: Option D is of lesser priority and is in this instance. Recommend the use of soft-bristled toothbrushes and stool softeners to protect mucous membranes; and if infection occurs, teach the patient to take antibiotics as prescribed; instruct the patient to take the full course of antibiotics even if symptoms improve or disappear.
- 4. Question A client with a pituitary tumor has had transsphenoidal hypophysectomy. Which of the following interventions would be appropriate for this client? o A. Place the client in Trendelenburg position for postural drainage o B. Encourage coughing and deep breathing every 2 hours o C. Elevate the head of the bed 30° o D. Encourage the Valsalva maneuver for
bowel movements
o A. Measure the urinary output
o B. Check the vital signs o C. Encourage increased fluid intake o D. Weigh the client Correct Answer: B. Check the vital signs A large amount of fluid loss can cause fluid and electrolyte imbalance that should be corrected. The loss of electrolytes would be reflected in the vital signs. Monitor for signs of hypovolemic shock (e.g., tachycardia, tachypnea, hypotension). Frequent assessment can detect changes early for rapid intervention. Polyuria causes decreased circulatory blood volume. o Option A: Measuring the urinary output is important, but the stem already says that the client has polyuria. Monitor intake and output. Report urine volume greater than 200 mL for each of 2 consecutive hours or 500 mL in a 2-hour period. With DI, the patient voids large urine volumes independent of the fluid intake. Urine output ranges from 2 to 3 L/day with renal DI to greater than 10 L/day with central DI. o Option C: Encouraging fluid intake will not correct the problem. Allow the patient to drink water at will. Patients with intact thirst mechanisms may maintain fluid balance by drinking huge quantities of water to compensate for the amount they urinate. Patients prefer cold or ice water. o Option D: Weighing the client is not necessary at this time. Monitor serum and urine osmolality. Urine osmolality will be decreased and serum osmolality will increase. Monitor urine-specific gravity. This may be 1.005 or less.
- 6. Question A client with hemophilia has a nosebleed. Which nursing
o B. Pack the nares tightly with gauze to apply pressure to the source of bleeding o C. Pinch the soft lower part of the nose for a minimum of 5 minutes o D. Apply ice packs to the forehead and back of the neck Correct Answer: C. Pinch the soft lower part of the nose for a minimum of 5 minutes The client should be positioned upright and leaning forward, to prevent aspiration of blood. Usual sites of external bleeding may include the bleeding in the mouth from a cut, bite, or from cutting or losing a tooth; nosebleeds for no obvious reasons; heavy bleeding from a minor cut, or bleeding from a cut that resumes after stopping for a short time. Hemophiliacs do not bleed faster or more frequently. Instead, they bleed longer due to a deficiency of clotting factor. Clients are often aware of bleeding before clinical manifestation. Bleeding can be life- threatening to these clients.
- 7. o Option A: Direct pressure to the nose stops the bleeding. Apply manual or mechanical pressure if active bleeding is noted. If spontaneous or traumatic bleeding is evident, monitor vital signs. o Option B: If a pack is necessary, the nares are loosely packed. Controlling bleeding is a nursing priority. Nasal packing should be avoided, because the subsequent removal of the packing may precipitate further bleeding. o Option D: Ice packs should be applied directly to the nose as well. Assess for any signs of bruising and bleeding (note the extent of bleeding). Assess for prolonged bleeding after minor injuries.
Question
A client has had a unilateral adrenalectomy to remove a tumor. To prevent complications, the most important measurement in
the immediate postoperative period for the nurse to take is: o A. Blood pressure
relatively low risk of postoperative complications, with an overall rate of 3.6%. Improved patient outcomes and decreased hospital costs have been demonstrated when adrenalectomy is performed by a high-volume adrenal surgeon (>/= adrenalectomies/year).
- 8. Question A client with Addison’s disease has been admitted with a history of nausea and vomiting for the past 3 days. The client is receiving IV glucocorticoids (Solu-Medrol). Which of the following interventions would the nurse implement? o A. Daily weights o B. Intake/output measurements o C. Sodium and potassium levels monitored o D. Glucometer readings as ordered Correct Answer: D. Glucometer readings as ordered IV glucocorticoids raise the glucose levels and often require coverage with insulin. Cortisone and prednisone replace cortisol deficits, which will promote sodium reabsorption. Fludrocortisone is a mineralocorticoid for patients who require aldosterone replacement to promote sodium and water replacement. Acute adrenal insufficiency is a medical emergency requiring immediate fluid and corticosteroid administration. If treated for adrenal crisis, the patient requires IV hydrocortisone initially; usually by the second day, administration can be converted to an oral form of replacement. o Option A: Daily weights are unnecessary. Monitor trends in weight. This provides documentation of weight loss trends. Weight loss is a common manifestation of adrenal insufficiency. o Option B: Intake/output measurements are not necessary at this time. Assess vital signs, especially noting BP and HR for orthostatic changes. A BP drop of more than 15 mm Hg when changing from supine to sitting position, with a concurrent elevation of 15 beats per min in HR, indicates reduced circulating fluids.
Option A: The crash cart would be needed in respiratory distress but wou Option C: The drainage would occur in hemorrhage. Check dressing freq Option D: Hypertension occurs in a thyroid storm. Monitor vital signs noti Correct Answer: B. Check the calcium level The parathyroid glands are responsible for calcium production and can be damage deficiency and decreased renal perfusion), hyponatremia (related to decreased aldosterone and impaired free water clearance), and increase in blood urea nitrogen (related to decreased glomerular filtration from ).
- 9. Question A client had a total thyroidectomy yesterday. The client is complaining of tingling around the mouth and in the fingers and toes. What would the nurse’s next action be? o A. Obtain a crash cart o B. Check the calcium level o C. Assess the dressing for drainage o D. Assess the blood pressure for hypertension
thyroidectomy may result in increased hormone release, causing thyroid storm.
- 10. Question A 32-year-old mother of three is brought to the clinic. Her pulse is 52, there is a weight gain of 30 pounds in 4 months, and the client is wearing two sweaters. The client is diagnosed with hypothyroidism. Which of the following nursing diagnoses is of highest priority? o A. Impaired physical mobility related to decreased endurance o B. Hypothermia r/t decreased metabolic rate o C. Disturbed thought processes r/t interstitial edema o D. Decreased cardiac output r/t bradycardia Correct Answer: D. Decreased cardiac output r/t bradycardia The decrease in pulse can affect the cardiac output and lead to shock, which would take precedence over the other choices. Protect against coldness. Provide extra layers of clothing or extra blankets. Discourage and avoid the use of external heat sources. Monitor patient’s body temperature. o Option A: Impaired physical mobility is not applicable to a client with hypothyroidism. Promote rest. Space activities to promote rest and exercise as tolerated. Assess the client’s ability to perform activities of daily living (ADLs). The client may experience fatigue with minimal exertion due to a slow metabolic rate. This symptom hinder the client’s ability to perform daily activities (e.g., self- care, eating) o Option B: Hypothermia is correct but not a priority. Teach the expected benefits and possible side effects. The client should report symptoms such as
Option A: An area of the groin or the artery in the wrist or hand will be cle Option C: Warmth does not indicate that clots are dissolving. If the angiog Correct Answer: Answer: B. “That feeling of warmth is normal when the dye is It is normal for the client to have a warm sensation when dye is injected. The client with hypothyroidism have decreased appetite. This opposite relationship between weight gain and decreased appetite is a manifestation found in hypothyroidism.
- 11. Question The client is having an arteriogram. During the procedure, the client tells the nurse, “I’m feeling really hot.” Which response would be best? o A. "You are having an allergic reaction. I will get an order for Benadryl." o B. "That feeling of warmth is normal when the dye is injected." o C. "That feeling of warmth indicates that the clots in the coronary vessels are dissolving." o D. "I will tell your doctor and let him explain to you the reason for the hot feeling that you are experiencing."
Correct Answer: D. The nurse wears gloves to take the client’s vital signs. It is not necessary to wear gloves to take the vital signs of the client. If the client has an active infection with methicillin- resistant Staphylococcus aureus, gloves should be worn. a balloon angioplasty or stent placement may be performed at the same time. When the procedure is completed, the catheter will be removed, and pressure will be held on the entry site for 10- minutes to stop any bleeding. The client may have a compression device applied to stop the bleeding from the angiogram site. This device may stay in place for 1- ½ hours. o Option D: This statement indicates that the nurse believes that the hot feeling is abnormal, so it is. Once the angiogram is completed the client may be on bedrest for 4-6 hours or until he has recovered from sedation. The client will be allowed to eat and will be encouraged to drink fluids to flush the
- 12. Question The nurse is observing several healthcare workers providing care. Which action by the healthcare worker indicates a need for further teaching? o A. The nursing assistant wears gloves while giving the client a bath. o B. The nurse wears goggles while drawing blood from the client. o C. The doctor washes his hands before examining the client. o D. The nurse wears gloves to take the client’s vital signs.
