PEARSON NCLEX-RN QUESTIONS & ANSWERS GRADED A+ WITH
RATIONALES
6. The nurse is instructing a client with Egg salad on wheat bread, carrot sticks, lettuce salad, raisin pie
iron- deficiency anemia. Which of the Egg yolks, wheat bread, carrots, raisins, and green, leafy
following meal vegetables are all high in iron, which is an important mineral for
plans would the nurse expect the client to this client. Roast beef, cabbage, and pork chops are also high
select? Roast beef, gelatin salad, green in iron, but the side dishes
beans, and peach pie accompanying these choices are not
Chicken salad sandwich, coleslaw, French
fries, ice cream
Egg salad on wheat bread, carrot sticks, lettuce
salad, raisin pie
Pork chop, creamed potatoes, corn, and
coconut cake
7. Clients with sickle cell anemia are taught to A bus trip to the Museum of Natural History
avoid activities that cause hypoxia and A family vacation in the Rocky Mountains at high altitudes, cold
hypoxemia. Which of the following activities temperatures, and airplane travel can cause sickling episodes
would the nurse recommend? and should be avoided
A family vacation in the Rocky Mountains
Chaperoning the local boys club on a snow-
skiing trip
Traveling by airplane for business trips
A bus trip to the Museum of Natural History
8. The nurse is conducting an admission Examine the tongue
assessment of a client with vitamin B12 The tongue is smooth and beefy red in the client with vitamin
deficiency. Which of the following would the B12 deficiency, so examining the tongue should be included in
nurse include in the physical assessment? the physical assessment.
Palpate the spleen
Take the blood pressure
Examine the feet for petechiae
Examine the tongue
9. An African American female comes to the Roof of the mouth
outpatient clinic. The physician suspects vitamin The oral mucosa and hard palate (roof of the mouth) are the best
B12 deficiency anemia. Because jaundice is indicators of jaundice in dark-skinned persons. The conjunctiva
often a clinical manifestation of this type of can have normal deposits of fat, which give a yellowish hue;
anemia, what body part would be the best thus, answer A is
indicator? incorrect. The soles of the feet can be yellow if they are
Conjunctiva of the calloused, making answer B incorrect; the shins would be an
eye Soles of the area of darker
feet pigment
Roof of the mouth
Shins
10. The nurse is conducting a physical Respirations 28 shallow
assessment on a client with anemia. Which When there are fewer red blood cells, there is less hemoglobin
of the following and less oxygen. Therefore, the client is often short of breath
clinical manifestations would be most
indicative of the anemia?
BP 146/88
Respirations 28 shallow
Weight gain of 10 pounds in 6
,months Pink complexion
11. The nurse is teaching the client with "I will drink 500mL of fluid or less each day."
polycythemia vera about prevention of The client with polycythemia vera is at risk for thrombus
complications of the disease. Which of the formation. Hydrating the client with at least 3L of fluid per
following statements by the client indicates a day is important in preventing clot formation
need for further teaching?
"I will drink 500mL of fluid or less each
day." "I will wear support hose when I
am up."
"I will use an electric razor for
shaving." "I will eat foods low in
iron."
18. The home health nurse is visiting a client with Bleeding precautions
autoimmune thrombocytopenic purpura (ATP). The normal platelet count is 120,000–400, Bleeding occurs in
The client's platelet count currently is 80, It clients with low platelets. The priority is to prevent and
will be most important to teach the client minimize bleeding.
and family about:
Bleeding precautions
Prevention of falls
Oxygen therapy
Conservation of energy
19. A client with a pituitary tumor has had a Elevate the head of the bed 30°
transphenoidal hyposphectomy. Which of the Elevating the head of the bed 30° avoids pressure on the sella
following interventions would be appropriate turcica and alleviates headaches. Answers A, B, and D are
for this client? incorrect because Trendelenburg, Valsalva maneuver, and
Place the client in Trendelenburg position for coughing all increase the
postural drainage intracranial pressure.
Encourage coughing and deep breathing every
2 hours
Elevate the head of the bed 30°
Encourage the Valsalva maneuver for bowel
movements
20. The client with a history of diabetes Check the vital signs
insipidus is admitted with polyuria, The large amount of fluid loss can cause fluid and electrolyte
polydipsia, and mental confusion. The priority imbalance that should be corrected. The loss of electrolytes
intervention for this client is: Measure the would be reflected in the vital signs. Measuring the urinary
urinary output output is important, but the stem
Check the vital signs already says that the client has polyuria, so answer A is incorrect.
Encourage increased fluid intake Encouraging fluid intake will not correct the problem, making
Weigh the client answer C incorrect.
, 21. A client with hemophilia has a nosebleed. Pinch the soft lower part of the nose for a minimum of 5 minutes
Which nursing action is most appropriate to The client should be positioned upright and leaning forward, to
control the prevent aspiration of blood. Answers A, B, and D are incorrect
bleeding? because direct
Place the client in a sitting position with the pressure to the nose stops the bleeding, and ice packs should be
head hyperextended applied directly to the nose as well. If a pack is necessary, the
Pack the nares tightly with gauze to apply nares are loosely packed.
pressure to the source of bleeding
Pinch the soft lower part of the nose for a
minimum of 5 minutes
Apply ice packs to the forehead and back of
the neck
22. A client has had a unilateral Blood pressure
adrenalectomy to remove a tumor. To Blood pressure is the best indicator of cardiovascular collapse
prevent complications, the most in the client who has had an adrenal gland removed. The
important measurement in the immediate remaining gland might have been suppressed due to the
post-operative period for the nurse to tumor activity. Temperature
take is: would be an indicator of infection, decreased output would be a
Blood pressure clinical manifestation but would take longer to occur than
Temperature blood pressure changes, and specific gravity changes occur
Output with other disorders
Specific
gravity
A client with Addison's disease has been Glucometer readings as ordered
admitted with a history of nausea and vomiting IV glucocorticoids raise the glucose levels and often require
for the past 3 days. The client is receiving IV coverage with insulin. Answer B is not necessary at this time,
glucocorticoids sodium and
(Solu-Medrol). Which of the following potassium levels would be monitored when the client is
interventions would the nurse receiving mineral corticoids, and daily weights is
implement? Glucometer readings unnecessary
as ordered
Intake/output measurements
Sodium and potassium levels
monitored Daily weights
32. The nurse is checking the client's Phlebostatic axis
central venous pressure. The nurse should The phlebostatic axis is located at the fifth intercostals space
place the zero of the manometer at the: midaxillary line and is the correct placement of the manometer.
Phlebostatic The PMI or point of maximal impulse is located at the fifth
axis PMI intercostals space midclavicular line, so answer B is incorrect.
Erb's point Erb’s point is the point at which you can
Tail of Spence hear the valves close simultaneously, making answer C incorrect.
The Tail of Spence (the upper outer quadrant) is the area
where most breast
cancers are located and has nothing to do with placement of a
manometer
RATIONALES
6. The nurse is instructing a client with Egg salad on wheat bread, carrot sticks, lettuce salad, raisin pie
iron- deficiency anemia. Which of the Egg yolks, wheat bread, carrots, raisins, and green, leafy
following meal vegetables are all high in iron, which is an important mineral for
plans would the nurse expect the client to this client. Roast beef, cabbage, and pork chops are also high
select? Roast beef, gelatin salad, green in iron, but the side dishes
beans, and peach pie accompanying these choices are not
Chicken salad sandwich, coleslaw, French
fries, ice cream
Egg salad on wheat bread, carrot sticks, lettuce
salad, raisin pie
Pork chop, creamed potatoes, corn, and
coconut cake
7. Clients with sickle cell anemia are taught to A bus trip to the Museum of Natural History
avoid activities that cause hypoxia and A family vacation in the Rocky Mountains at high altitudes, cold
hypoxemia. Which of the following activities temperatures, and airplane travel can cause sickling episodes
would the nurse recommend? and should be avoided
A family vacation in the Rocky Mountains
Chaperoning the local boys club on a snow-
skiing trip
Traveling by airplane for business trips
A bus trip to the Museum of Natural History
8. The nurse is conducting an admission Examine the tongue
assessment of a client with vitamin B12 The tongue is smooth and beefy red in the client with vitamin
deficiency. Which of the following would the B12 deficiency, so examining the tongue should be included in
nurse include in the physical assessment? the physical assessment.
Palpate the spleen
Take the blood pressure
Examine the feet for petechiae
Examine the tongue
9. An African American female comes to the Roof of the mouth
outpatient clinic. The physician suspects vitamin The oral mucosa and hard palate (roof of the mouth) are the best
B12 deficiency anemia. Because jaundice is indicators of jaundice in dark-skinned persons. The conjunctiva
often a clinical manifestation of this type of can have normal deposits of fat, which give a yellowish hue;
anemia, what body part would be the best thus, answer A is
indicator? incorrect. The soles of the feet can be yellow if they are
Conjunctiva of the calloused, making answer B incorrect; the shins would be an
eye Soles of the area of darker
feet pigment
Roof of the mouth
Shins
10. The nurse is conducting a physical Respirations 28 shallow
assessment on a client with anemia. Which When there are fewer red blood cells, there is less hemoglobin
of the following and less oxygen. Therefore, the client is often short of breath
clinical manifestations would be most
indicative of the anemia?
BP 146/88
Respirations 28 shallow
Weight gain of 10 pounds in 6
,months Pink complexion
11. The nurse is teaching the client with "I will drink 500mL of fluid or less each day."
polycythemia vera about prevention of The client with polycythemia vera is at risk for thrombus
complications of the disease. Which of the formation. Hydrating the client with at least 3L of fluid per
following statements by the client indicates a day is important in preventing clot formation
need for further teaching?
"I will drink 500mL of fluid or less each
day." "I will wear support hose when I
am up."
"I will use an electric razor for
shaving." "I will eat foods low in
iron."
18. The home health nurse is visiting a client with Bleeding precautions
autoimmune thrombocytopenic purpura (ATP). The normal platelet count is 120,000–400, Bleeding occurs in
The client's platelet count currently is 80, It clients with low platelets. The priority is to prevent and
will be most important to teach the client minimize bleeding.
and family about:
Bleeding precautions
Prevention of falls
Oxygen therapy
Conservation of energy
19. A client with a pituitary tumor has had a Elevate the head of the bed 30°
transphenoidal hyposphectomy. Which of the Elevating the head of the bed 30° avoids pressure on the sella
following interventions would be appropriate turcica and alleviates headaches. Answers A, B, and D are
for this client? incorrect because Trendelenburg, Valsalva maneuver, and
Place the client in Trendelenburg position for coughing all increase the
postural drainage intracranial pressure.
Encourage coughing and deep breathing every
2 hours
Elevate the head of the bed 30°
Encourage the Valsalva maneuver for bowel
movements
20. The client with a history of diabetes Check the vital signs
insipidus is admitted with polyuria, The large amount of fluid loss can cause fluid and electrolyte
polydipsia, and mental confusion. The priority imbalance that should be corrected. The loss of electrolytes
intervention for this client is: Measure the would be reflected in the vital signs. Measuring the urinary
urinary output output is important, but the stem
Check the vital signs already says that the client has polyuria, so answer A is incorrect.
Encourage increased fluid intake Encouraging fluid intake will not correct the problem, making
Weigh the client answer C incorrect.
, 21. A client with hemophilia has a nosebleed. Pinch the soft lower part of the nose for a minimum of 5 minutes
Which nursing action is most appropriate to The client should be positioned upright and leaning forward, to
control the prevent aspiration of blood. Answers A, B, and D are incorrect
bleeding? because direct
Place the client in a sitting position with the pressure to the nose stops the bleeding, and ice packs should be
head hyperextended applied directly to the nose as well. If a pack is necessary, the
Pack the nares tightly with gauze to apply nares are loosely packed.
pressure to the source of bleeding
Pinch the soft lower part of the nose for a
minimum of 5 minutes
Apply ice packs to the forehead and back of
the neck
22. A client has had a unilateral Blood pressure
adrenalectomy to remove a tumor. To Blood pressure is the best indicator of cardiovascular collapse
prevent complications, the most in the client who has had an adrenal gland removed. The
important measurement in the immediate remaining gland might have been suppressed due to the
post-operative period for the nurse to tumor activity. Temperature
take is: would be an indicator of infection, decreased output would be a
Blood pressure clinical manifestation but would take longer to occur than
Temperature blood pressure changes, and specific gravity changes occur
Output with other disorders
Specific
gravity
A client with Addison's disease has been Glucometer readings as ordered
admitted with a history of nausea and vomiting IV glucocorticoids raise the glucose levels and often require
for the past 3 days. The client is receiving IV coverage with insulin. Answer B is not necessary at this time,
glucocorticoids sodium and
(Solu-Medrol). Which of the following potassium levels would be monitored when the client is
interventions would the nurse receiving mineral corticoids, and daily weights is
implement? Glucometer readings unnecessary
as ordered
Intake/output measurements
Sodium and potassium levels
monitored Daily weights
32. The nurse is checking the client's Phlebostatic axis
central venous pressure. The nurse should The phlebostatic axis is located at the fifth intercostals space
place the zero of the manometer at the: midaxillary line and is the correct placement of the manometer.
Phlebostatic The PMI or point of maximal impulse is located at the fifth
axis PMI intercostals space midclavicular line, so answer B is incorrect.
Erb's point Erb’s point is the point at which you can
Tail of Spence hear the valves close simultaneously, making answer C incorrect.
The Tail of Spence (the upper outer quadrant) is the area
where most breast
cancers are located and has nothing to do with placement of a
manometer
