NCLEX-PN Practice Questions Quizlet
Question 1 of 5.
A client, age 28, was recently diagnosed with Hodgkin's disease. After staging, therapy is planned to include combination radiation therapy and systemic chemotherapy with MOPPâ€â€nitrogen mustard, vincristine (Oncovin), prednisone, and procarbazine. In planning care for this client, the nurse should anticipate which of the following side effects to contribute to a sense of altered body image?
A. cushingoid appearance
B. alopecia
C. temporary or permanent sterility
D. pathologic fractures
Explanation: Alopecia, or hair loss, is a common side effect of chemotherapy (e.g., vincristine) and radiation, significantly affecting body image. Pathologic fractures are not typical, and sterility or cushingoid appearance have less direct impact on body image. Physiological Adaptation
Question 2 of 5.
The nurse is caring for an adult who is being admitted to the unit for detoxification from alcohol. Which comment is the client most likely to make at this time?
A. I am so sorry for any trouble I've caused my family.
B. I'm not really an alcoholic you know. I'm doing this to please my wife.
C. I am so embarrassed. I know drinking is wrong.
D. My friends and family all tell me I am not an alcoholic.
Explanation: Denial is common in early alcohol detoxification, with clients often minimizing their problem or attributing treatment to external pressures.
Question 3 of 5.
A cooling blanket has been ordered for an adult who has a head injury and is running high fevers. The client starts shivering. What action is most appropriate for the LPN?
A. Add more blankets to warm up the client
B. Report immediately to the charge nurse
C. Increase the temperature of the cooling blanket
D. Continue to monitor the client because shivering is expected
Explanation: Shivering indicates the cooling blanket may be too cold, risking complications; reporting to the charge nurse ensures proper adjustment.
Question 4 of 5.
An adult is taking warfarin daily. The client's international normalized ratio (INR) is 2.4. Which nursing action is most appropriate?
A. Increase the dose of warfarin by 2 mg
B. Withhold the warfarin and notify the physician
C. Administer the warfarin as ordered
D. Call the physician for a decrease in dosage
Explanation: An INR of 2.4 is within the therapeutic range (2.0-3.0) for anticoagulation, indicating the dose should be continued as ordered.
Question 5 of 5.
The nurse is caring for a client who is prescribed cholestyramine (Questran). Which comment by the client is of most concern to the nurse?
A. I have a grapefruit almost every day for breakfast.'
B. My muscles were very tired after exercising yesterday.'
C. I have lost three pounds in the last two weeks.'
D. When the nurse drew my blood last time, he left a bruise.'
Explanation: Muscle fatigue may indicate myopathy, a rare but serious side effect of cholestyramine, requiring immediate evaluation. Grapefruit, weight loss, and bruising are not directly related to cholestyramine risks.