NCLEX-RN
NCLEX RN Predictor Exam Questions
Extract:
Question 1 of 5
A nurse is administering a blood transfusion to a client on the oncology unit. Which clinical manifestation indicates an acute hemolytic reaction to the blood?
Correct Answer: A
Rationale: Low back pain is a hallmark of acute hemolytic reaction due to immune-mediated hemolysis. Headache (
B) and urticaria (
C) suggest allergic reactions, and neck vein distention (
D) suggests fluid overload.
Question 2 of 5
The nurse documents a client's surgical incision as having red granulated tissue. This indicates that the wound is:
Correct Answer: D
Rationale: The wound is healing properly and is filled with red granulated tissue and fragile capillaries.
Question 3 of 5
The nurse notes multiple bruises on the arms and legs of a newly admitted client with lupus. The client states, 'I get them whenever I bump into anything.' The nurse would expect to note a decrease in which of the following laboratory tests?
Correct Answer: A
Rationale: Thrombocytopenia, a decrease in platelets, occurs in lupus and causes a decrease in blood coagulation and thrombus formation. Clients with lupus will have a decrease in the WBC count decreasing their resistance to infection. Clients with lupus may have a decrease in the hemoglobin level causing anemia. Leukopenia, a decrease in white blood cells, is seen in lupus and decreases resistance to infection.
Question 4 of 5
A 52-year-old client's abdominal aortic aneurysm ruptured. She received rapid massive blood transfusions for bleeding. One potential complication of blood administration for which she is especially at risk is:
Correct Answer: C
Rationale: Massive transfusions can cause hypocalcemia due to citrate in stored blood binding with calcium, especially in rapid transfusions.
Question 5 of 5
Assessment of the client's skin reveals numerous café au lait spots over the trunk. These changes are associated with which diagnosis?
Correct Answer: B
Rationale: Café au lait spots are characteristic of neurofibromatosis a genetic disorder affecting nerve tissue. They are not associated with polycythemia vera thalassemia major or acoustic neuroma.