SCF-NCLEX Review-Practice Questions
Cholinergic vs. Adrenergic - Adrenergic is called the sympathetic line (SNS) while cholinergic is
called the parasympathetic line (PNS).
The nurse should instruct the client to allow others to assist with household chores to reduce the risk for
joint injury and to give the client the opportunity to rest.
The nurse should instruct the client to use on only ONE small pillow, placed behind the head, while in
bed to prevent flexion contracture's.
A nurse is providing teaching to a client who has an allergy to peanuts. Which of the following
instructions is the priority to include in the teaching?
a. inform other health care professionals of the allergy
b. wear a medical id tag
c. carry and emergency anaphylaxis kit
d. keep a food diary - Answer = C
The greatest risk to the client is injury or death from an anaphylactic reaction. Therefore, the priority
instruction for the client is to be prepared for emergency treatment by carrying an emergency
anaphylaxis kit.
The nurse should instruct the client to wear a medical ID tag. However, this is not the priority instruction
to include in the teaching.
With acute leukemia, what can you expect to see with the following lab values. (WBC, Hgb, Hct,
Platelets) - elevated WBC
decreased Hgb
decreased Hct
decreased platelets
,A nurse is educating a client who is scheduled for a kidney transplant. Which of the following
information about hyper acute rejection should the nurse include in the teaching?
a. hyper acute rejection can occur during the first few weeks after the transplant
b. if hyper acute rejection occurs, the kidney can become enlarged
c. the organ will need to be removed if hyper acute rejection occurs
d. immunosuppressive therapy is given to reverse hyper acute rejection - Answer = C
removing the transplanted organ is the only tx for hyper acute rejection, due to the widespread clotting
cascade that leads to ischemic necrosis of the transplant kidney
hyper acute rejection occurs immediately following transplantation. Acute rejection occurs during the
first few weeks following the client's transplant.
A nurse is caring for a client who has viral pneumonia. Which of the following findings should the nurse
report to the provider immediately?
a. negative blood culture
b. left shift in WBC differential
c. oxygen saturation 93%
d. crackles heard on auscultation - Answer = b
When using the urgent vs non urgent approach to client care, the nurse should determine that the
priority finding is a left shift in the client's WBC differential, which indicates that the pneumonia is of
bacterial origin, rather than viral. The left shift can be manifestation of sepsis, and the nurse should
report this finding to the provider. left shift also means an acute infection.
Crackles heard is non urgent because it is an expected finding.
,Methotrexate can cause leukopenia due to bone marrow suppression, which can increase the client's
risk for infection.
The nurse should instruct the client to increase his intake of folic acid, not vit D, to help decrease the
adverse effects of methotrexate.
A nurse is providing discharge teaching for a client who is HIV positive. Which of the following
instructions should the nurse include in the teaching?
a. clean bathroom surfaces with full strength bleach
b. discard beverages that have been unrefrigerated for 1 hr
c. wash laundry soiled with a body fluid in warm water
d. work in the garden for exercise - Answer = b
Bacteria can grow in open, unrefrigerated beverages, which places the client at risk for infection.
With laundry HOT water should be used, not warm.
A nurse is assessing a client who has HIV. Which of the following findings should cause the nurse to
suspect that the client's diagnosis has progressed to AIDS?
a. small, purple-colored skin leasions
b. fever and diarrhea lasting longer than 1 month
c. persistent, generalized lymphadenopathy
d. CD4-T cells decreased to 750 cells/mm - Answer = a
purple-colored skin lesions is an indication that the client has acquired Kaposi's sarcoma, which is an
AIDS-defining illness.
CD4-T cell count of 750 is an indication of HIV. Below 200 is an indication of AIDS.
, A nurse is caring for a client who has non-Hodgkin's lymphoma and is receiving chemotherapy. Which of
the following is the priority assessment finding?
a. loss of body hair
b. report of anorexia
c. mucositis of the oral cavity
d. erythema at the IV insertion site - Answer = d
The greatest risk to the client is injury to the tissue due to extravasation of chemotherapy. Erythema a
the IV insertion site can indicate extravasation is occurring, which can lead to infection and tissue loss.
This is the priority assessment finding.
sores in the mouth is an expected adverse effect of chemotherapy. Therefore, another assessment
finding is the priority.
A nurse is reviewing the laboratory report for a client who has Hodgkin's lymphoma. Which of the
following findings should the nurse expect?
a. overgrowth of B-lymphocyte plasma cells
b. Reed-Sternberg cells
c. Epstein-Barr virus
d. overproduction of blast phase cells - Answer = b
Reed-Sternberg cells are cancer cells specific to a client who has Hodgkin's lymphoma.
The nurse should expect a client who has multiple myeloma to have an overgrowth of B-lymphocyte
plasma cells.
If the answer is "watch it or observe it, then come back"... THAT IS ALWAYS THE WRONG ANSWER -
N/A
Cholinergic vs. Adrenergic - Adrenergic is called the sympathetic line (SNS) while cholinergic is
called the parasympathetic line (PNS).
The nurse should instruct the client to allow others to assist with household chores to reduce the risk for
joint injury and to give the client the opportunity to rest.
The nurse should instruct the client to use on only ONE small pillow, placed behind the head, while in
bed to prevent flexion contracture's.
A nurse is providing teaching to a client who has an allergy to peanuts. Which of the following
instructions is the priority to include in the teaching?
a. inform other health care professionals of the allergy
b. wear a medical id tag
c. carry and emergency anaphylaxis kit
d. keep a food diary - Answer = C
The greatest risk to the client is injury or death from an anaphylactic reaction. Therefore, the priority
instruction for the client is to be prepared for emergency treatment by carrying an emergency
anaphylaxis kit.
The nurse should instruct the client to wear a medical ID tag. However, this is not the priority instruction
to include in the teaching.
With acute leukemia, what can you expect to see with the following lab values. (WBC, Hgb, Hct,
Platelets) - elevated WBC
decreased Hgb
decreased Hct
decreased platelets
,A nurse is educating a client who is scheduled for a kidney transplant. Which of the following
information about hyper acute rejection should the nurse include in the teaching?
a. hyper acute rejection can occur during the first few weeks after the transplant
b. if hyper acute rejection occurs, the kidney can become enlarged
c. the organ will need to be removed if hyper acute rejection occurs
d. immunosuppressive therapy is given to reverse hyper acute rejection - Answer = C
removing the transplanted organ is the only tx for hyper acute rejection, due to the widespread clotting
cascade that leads to ischemic necrosis of the transplant kidney
hyper acute rejection occurs immediately following transplantation. Acute rejection occurs during the
first few weeks following the client's transplant.
A nurse is caring for a client who has viral pneumonia. Which of the following findings should the nurse
report to the provider immediately?
a. negative blood culture
b. left shift in WBC differential
c. oxygen saturation 93%
d. crackles heard on auscultation - Answer = b
When using the urgent vs non urgent approach to client care, the nurse should determine that the
priority finding is a left shift in the client's WBC differential, which indicates that the pneumonia is of
bacterial origin, rather than viral. The left shift can be manifestation of sepsis, and the nurse should
report this finding to the provider. left shift also means an acute infection.
Crackles heard is non urgent because it is an expected finding.
,Methotrexate can cause leukopenia due to bone marrow suppression, which can increase the client's
risk for infection.
The nurse should instruct the client to increase his intake of folic acid, not vit D, to help decrease the
adverse effects of methotrexate.
A nurse is providing discharge teaching for a client who is HIV positive. Which of the following
instructions should the nurse include in the teaching?
a. clean bathroom surfaces with full strength bleach
b. discard beverages that have been unrefrigerated for 1 hr
c. wash laundry soiled with a body fluid in warm water
d. work in the garden for exercise - Answer = b
Bacteria can grow in open, unrefrigerated beverages, which places the client at risk for infection.
With laundry HOT water should be used, not warm.
A nurse is assessing a client who has HIV. Which of the following findings should cause the nurse to
suspect that the client's diagnosis has progressed to AIDS?
a. small, purple-colored skin leasions
b. fever and diarrhea lasting longer than 1 month
c. persistent, generalized lymphadenopathy
d. CD4-T cells decreased to 750 cells/mm - Answer = a
purple-colored skin lesions is an indication that the client has acquired Kaposi's sarcoma, which is an
AIDS-defining illness.
CD4-T cell count of 750 is an indication of HIV. Below 200 is an indication of AIDS.
, A nurse is caring for a client who has non-Hodgkin's lymphoma and is receiving chemotherapy. Which of
the following is the priority assessment finding?
a. loss of body hair
b. report of anorexia
c. mucositis of the oral cavity
d. erythema at the IV insertion site - Answer = d
The greatest risk to the client is injury to the tissue due to extravasation of chemotherapy. Erythema a
the IV insertion site can indicate extravasation is occurring, which can lead to infection and tissue loss.
This is the priority assessment finding.
sores in the mouth is an expected adverse effect of chemotherapy. Therefore, another assessment
finding is the priority.
A nurse is reviewing the laboratory report for a client who has Hodgkin's lymphoma. Which of the
following findings should the nurse expect?
a. overgrowth of B-lymphocyte plasma cells
b. Reed-Sternberg cells
c. Epstein-Barr virus
d. overproduction of blast phase cells - Answer = b
Reed-Sternberg cells are cancer cells specific to a client who has Hodgkin's lymphoma.
The nurse should expect a client who has multiple myeloma to have an overgrowth of B-lymphocyte
plasma cells.
If the answer is "watch it or observe it, then come back"... THAT IS ALWAYS THE WRONG ANSWER -
N/A
