NCLEX Practice Questions with rationales (with complete solution)

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After receiving report at the start of the evening shift, which of the following clients should the nurse attend to first? (a) A 34-year-old man undergoing treatment for non-Hodgkin lymphoma with a ... potassium level of 7.5 mEq/L. (b) A 21-year-old woman with sickle cell anemia with pain of 6 on a scale of 1-10. (c) A 55-year-old woman with ovarian cancer waiting to be discharged. (d) A 72-year-old man with chronic obstructive pulmonary disease (COPD) and a pulse oximetry of 96% on room air. - ✔✔Correct answer: (a) A 34-year-old man undergoing treatment for nonHodgkin lymphoma with a potassium level of 7.5 mEq/L. Rationale: Hyperkalemia is a potentially serious condition that, in a client undergoing treatment for non-Hodgkin lymphoma, could indicate tumour lysis syndrome. Patient (b) should be attended to, but her condition is not as urgent. Patients (c) and (d) do not require immediate attention. A 34-year-old woman who developed Stevens-Johnson syndrome while undergoing treatment with carbamazepine (Tegretol) is being transferred in stable condition from the intensive care unit to the medical unit. There are 4 beds available. The nurse knows the best choice of roommates for this client is which of the following? (a) A 40-year-old man with methicillin-resistant Staphylococcus aureus (MRSA). (b) A 28-year-old woman diagnosed with diarrhea. (c) A 72-year-old man with fever of unknown origin. (d) A 68-year-old woman with atrial fibrillation . - ✔✔Correct answer: (d) A 68-year-old woman with atrial fibrillation. Rationale: A client with Stevens-Johnson syndrome is likely to have severe skin integrity issues, including blistering and skin shedding, which can place the client at high risk for infection. Atrial fibrillation is not an infectious process. All other patients may be an infection risk for an individual with altered skin integrity [Show More]

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