PEARSON NCLEX-RN Questions & Rationales
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1. 2. A 30-year-old male from Haiti is brought to the emergency department in
sickle cell crisis. What is the best position for this client?
Side-lying with knees flexed
Knee-chest
High Fowler's with knees flexed
Semi-Fowler's with legs extended on the bed: Semi-Fowler's with legs extended
on the bed
2. 3. A 25-year-old male is admitted in sickle cell crisis. Which of the following
interventions would be of highest priority for this client?
Taking hourly blood pressures with mechanical cuff
Encouraging fluid intake of at least 200mL per hour
Position in high Fowler's with knee gatch raised
Administering Tylenol as ordered: Encouraging fluid intake of at least 200mL per
hour.
It is important to keep the client in sickle cell crisis hydrated to prevent further sickling
of the blood.
3. 4. Which of the following foods would the nurse encourage the client in
sickle cell crisis to eat?
Peaches
Cottage cheese
Popsicle
Lima beans: Popsicle.
Hydration is important in the client with sickle cell disease to prevent thrombus
formation. Popsicles, gelatin, juice, and pudding have high fluid content.
4. 5. A newly admitted client has sickle cell crisis. The nurse is planning
care based on assessment of the client. The client is complaining of severe
pain in his feet and hands. The pulse oximetry is 92. Which of the following
interventions would be implemented first? Assume that there are orders for
each intervention.
Adjust the room temperature
Give a bolus of IV fluids
Start O2
Administer meperidine (Demerol) 75mg IV push: Start O2.
The most prominent clinical manifestation of sickle cell crisis is pain. However,
the pulse oximetry indicates that oxygen levels are low; thus, oxygenation takes
precedence over pain relief.
5. 6. The nurse is instructing a client with iron-deficiency anemia. Which of the
following meal plans would the nurse expect the client to select?
Roast beef, gelatin salad, green beans, and peach pie
, PEARSON NCLEX-RN Questions & Rationales
Study online at https://quizlet.com/_cnpmsu
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: Egg salad on wheat
bread, carrot sticks, lettuce salad, raisin pie
Egg yolks, wheat bread, carrots, raisins, and green, leafy vegetables are all high in
iron, which is an important mineral for this client. Roast beef, cabbage, and pork
chops are also high in iron, but the side dishes accompanying these choices are not
6. 7. Clients with sickle cell anemia are taught to avoid activities that cause
hypoxia and hypoxemia. Which of the following activities would the nurse
recommend?
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: A bus trip to the Museum of Natural
History
A family vacation in the Rocky Mountains at high altitudes, cold temperatures, and
airplane travel can cause sickling episodes and should be avoided
7. 8. The nurse is conducting an admission assessment of a client with vitamin
B12 deficiency. Which of the following would the nurse include in the physical
assessment?
Palpate the spleen
Take the blood pressure
Examine the feet for petechiae
Examine the tongue: Examine the tongue
The tongue is smooth and beefy red in the client with vitamin B12 deficiency, so
examining the tongue should be included in the physical assessment.
8. 9. An African American female comes to the outpatient clinic. The physician
suspects vitamin B12 deficiency anemia. Because jaundice is often a clinical
manifestation of this type of anemia, what body part would be the best indica-
tor?
Conjunctiva of the eye
Soles of the feet
Roof of the mouth
Shins: Roof of the mouth
The oral mucosa and hard palate (roof of the mouth) are the best indicators of
jaundice in dark-skinned persons. The conjunctiva can have normal deposits of fat,
which give a yellowish hue; thus, answer A is incorrect. The soles of the feet can be
yellow if they are calloused, making answer B incorrect; the shins would be an area
of darker pigment
, PEARSON NCLEX-RN Questions & Rationales
Study online at https://quizlet.com/_cnpmsu
9. 10. The nurse is conducting a physical assessment on a client with anemia.
Which of the following 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: Respirations 28 shallow
When there are fewer red blood cells, there is less hemoglobin and less oxygen.
Therefore, the client is often short of breath
10. 11. The nurse is teaching the client with polycythemia vera about preven-
tion of complications of the disease. Which of the following statements by the
client indicates a 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.": "I will drink 500mL of fluid or less each day."
The client with polycythemia vera is at risk for thrombus formation. Hydrating the
client with at least 3L of fluid per day is important in preventing clot formation
11. 12. A 33-year-old male is being evaluated for possible acute leukemia.
Which of the following would the nurse inquire about as a part of the assess-
ment?
The client collects stamps as a hobby.
The client recently lost his job as a postal worker.
The client had radiation for treatment of Hodgkin's disease as a teenager.
The client's brother had leukemia as a child.: The client had radiation for treat-
ment of Hodgkin's disease as a teenager.
Radiation treatment for other types of cancer can result in leukemia. Some hobbies
and occupations involving chemicals are linked to leukemia, but not the ones in these
answers; therefore, answers A and B are incorrect. Answer D is incorrect because
the incidence of leukemia is higher in twins than in siblings.
12. 13. An African American client is admitted with acute leukemia. The nurse
is assessing for signs and symptoms of bleeding. Where is the best site for
examining for the presence of petechiae?
The abdomen
The thorax
The earlobes
The soles of the feet: The soles of the feet
Petechiae are not usually visualized on dark skin. The soles of the feet and palms
of the hand provide a lighter surface for assessing the client for petichiae.
, PEARSON NCLEX-RN Questions & Rationales
Study online at https://quizlet.com/_cnpmsu
13. 14. A client with acute leukemia is admitted to the oncology unit. Which of
the following would be most important for the nurse to inquire?
"Have you noticed a change in sleeping habits recently?"
"Have you had a respiratory infection in the last 6 months?"
"Have you lost weight recently?"
"Have you noticed changes in your alertness?": "Have you had a respiratory
infection in the last 6 months?"
The client with leukemia is at risk for infection and has often had recurrent respiratory
infections during the previous 6 months. Insomnolence, weight loss, and a decrease
in alertness also occur in leukemia, but bleeding tendencies and infections are the
primary clinical manifestations
14. 15. Which of the following would be the priority nursing diagnosis for the
adult client with acute leukemia?
Oral mucous membrane, altered related to chemotherapy
Risk for injury related to thrombocytopenia
Fatigue related to the disease process
Interrupted family processes related to life-threatening illness of a family
member: Risk for injury related to thrombocytopenia
The client with acute leukemia has bleeding tendencies due to decreased platelet
counts, and any injury would exacerbate the problem. The client would require close
monitoring for hemorrhage, which is of higher priority
15. 16. A 21-year-old male with Hodgkin's lymphoma is a senior at the local
university. He is engaged to be married and is to begin a new job upon
graduation. Which of the following diagnoses would be a priority for this
client?
Sexual dysfunction related to radiation therapy
Anticipatory grieving related to terminal illness
Tissue integrity related to prolonged bed rest
Fatigue related to chemotherapy: Sexual dysfunction related to radiation therapy
Radiation therapy often causes sterility in male clients and would be of primary
importance to this client. The psychosocial needs of the client are important to
address in light of the age and life choices. Hodgkin's disease, however, has a good
prognosis when diagnosed early.
16. 17. A client has autoimmune thrombocytopenic purpura. To determine the
client's response to treatment, the nurse would monitor:
Platelet count
White blood cell count
Potassium levels
Partial prothrombin time (PTT): Platelet count
Study online at https://quizlet.com/_cnpmsu
1. 2. A 30-year-old male from Haiti is brought to the emergency department in
sickle cell crisis. What is the best position for this client?
Side-lying with knees flexed
Knee-chest
High Fowler's with knees flexed
Semi-Fowler's with legs extended on the bed: Semi-Fowler's with legs extended
on the bed
2. 3. A 25-year-old male is admitted in sickle cell crisis. Which of the following
interventions would be of highest priority for this client?
Taking hourly blood pressures with mechanical cuff
Encouraging fluid intake of at least 200mL per hour
Position in high Fowler's with knee gatch raised
Administering Tylenol as ordered: Encouraging fluid intake of at least 200mL per
hour.
It is important to keep the client in sickle cell crisis hydrated to prevent further sickling
of the blood.
3. 4. Which of the following foods would the nurse encourage the client in
sickle cell crisis to eat?
Peaches
Cottage cheese
Popsicle
Lima beans: Popsicle.
Hydration is important in the client with sickle cell disease to prevent thrombus
formation. Popsicles, gelatin, juice, and pudding have high fluid content.
4. 5. A newly admitted client has sickle cell crisis. The nurse is planning
care based on assessment of the client. The client is complaining of severe
pain in his feet and hands. The pulse oximetry is 92. Which of the following
interventions would be implemented first? Assume that there are orders for
each intervention.
Adjust the room temperature
Give a bolus of IV fluids
Start O2
Administer meperidine (Demerol) 75mg IV push: Start O2.
The most prominent clinical manifestation of sickle cell crisis is pain. However,
the pulse oximetry indicates that oxygen levels are low; thus, oxygenation takes
precedence over pain relief.
5. 6. The nurse is instructing a client with iron-deficiency anemia. Which of the
following meal plans would the nurse expect the client to select?
Roast beef, gelatin salad, green beans, and peach pie
, PEARSON NCLEX-RN Questions & Rationales
Study online at https://quizlet.com/_cnpmsu
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: Egg salad on wheat
bread, carrot sticks, lettuce salad, raisin pie
Egg yolks, wheat bread, carrots, raisins, and green, leafy vegetables are all high in
iron, which is an important mineral for this client. Roast beef, cabbage, and pork
chops are also high in iron, but the side dishes accompanying these choices are not
6. 7. Clients with sickle cell anemia are taught to avoid activities that cause
hypoxia and hypoxemia. Which of the following activities would the nurse
recommend?
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: A bus trip to the Museum of Natural
History
A family vacation in the Rocky Mountains at high altitudes, cold temperatures, and
airplane travel can cause sickling episodes and should be avoided
7. 8. The nurse is conducting an admission assessment of a client with vitamin
B12 deficiency. Which of the following would the nurse include in the physical
assessment?
Palpate the spleen
Take the blood pressure
Examine the feet for petechiae
Examine the tongue: Examine the tongue
The tongue is smooth and beefy red in the client with vitamin B12 deficiency, so
examining the tongue should be included in the physical assessment.
8. 9. An African American female comes to the outpatient clinic. The physician
suspects vitamin B12 deficiency anemia. Because jaundice is often a clinical
manifestation of this type of anemia, what body part would be the best indica-
tor?
Conjunctiva of the eye
Soles of the feet
Roof of the mouth
Shins: Roof of the mouth
The oral mucosa and hard palate (roof of the mouth) are the best indicators of
jaundice in dark-skinned persons. The conjunctiva can have normal deposits of fat,
which give a yellowish hue; thus, answer A is incorrect. The soles of the feet can be
yellow if they are calloused, making answer B incorrect; the shins would be an area
of darker pigment
, PEARSON NCLEX-RN Questions & Rationales
Study online at https://quizlet.com/_cnpmsu
9. 10. The nurse is conducting a physical assessment on a client with anemia.
Which of the following 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: Respirations 28 shallow
When there are fewer red blood cells, there is less hemoglobin and less oxygen.
Therefore, the client is often short of breath
10. 11. The nurse is teaching the client with polycythemia vera about preven-
tion of complications of the disease. Which of the following statements by the
client indicates a 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.": "I will drink 500mL of fluid or less each day."
The client with polycythemia vera is at risk for thrombus formation. Hydrating the
client with at least 3L of fluid per day is important in preventing clot formation
11. 12. A 33-year-old male is being evaluated for possible acute leukemia.
Which of the following would the nurse inquire about as a part of the assess-
ment?
The client collects stamps as a hobby.
The client recently lost his job as a postal worker.
The client had radiation for treatment of Hodgkin's disease as a teenager.
The client's brother had leukemia as a child.: The client had radiation for treat-
ment of Hodgkin's disease as a teenager.
Radiation treatment for other types of cancer can result in leukemia. Some hobbies
and occupations involving chemicals are linked to leukemia, but not the ones in these
answers; therefore, answers A and B are incorrect. Answer D is incorrect because
the incidence of leukemia is higher in twins than in siblings.
12. 13. An African American client is admitted with acute leukemia. The nurse
is assessing for signs and symptoms of bleeding. Where is the best site for
examining for the presence of petechiae?
The abdomen
The thorax
The earlobes
The soles of the feet: The soles of the feet
Petechiae are not usually visualized on dark skin. The soles of the feet and palms
of the hand provide a lighter surface for assessing the client for petichiae.
, PEARSON NCLEX-RN Questions & Rationales
Study online at https://quizlet.com/_cnpmsu
13. 14. A client with acute leukemia is admitted to the oncology unit. Which of
the following would be most important for the nurse to inquire?
"Have you noticed a change in sleeping habits recently?"
"Have you had a respiratory infection in the last 6 months?"
"Have you lost weight recently?"
"Have you noticed changes in your alertness?": "Have you had a respiratory
infection in the last 6 months?"
The client with leukemia is at risk for infection and has often had recurrent respiratory
infections during the previous 6 months. Insomnolence, weight loss, and a decrease
in alertness also occur in leukemia, but bleeding tendencies and infections are the
primary clinical manifestations
14. 15. Which of the following would be the priority nursing diagnosis for the
adult client with acute leukemia?
Oral mucous membrane, altered related to chemotherapy
Risk for injury related to thrombocytopenia
Fatigue related to the disease process
Interrupted family processes related to life-threatening illness of a family
member: Risk for injury related to thrombocytopenia
The client with acute leukemia has bleeding tendencies due to decreased platelet
counts, and any injury would exacerbate the problem. The client would require close
monitoring for hemorrhage, which is of higher priority
15. 16. A 21-year-old male with Hodgkin's lymphoma is a senior at the local
university. He is engaged to be married and is to begin a new job upon
graduation. Which of the following diagnoses would be a priority for this
client?
Sexual dysfunction related to radiation therapy
Anticipatory grieving related to terminal illness
Tissue integrity related to prolonged bed rest
Fatigue related to chemotherapy: Sexual dysfunction related to radiation therapy
Radiation therapy often causes sterility in male clients and would be of primary
importance to this client. The psychosocial needs of the client are important to
address in light of the age and life choices. Hodgkin's disease, however, has a good
prognosis when diagnosed early.
16. 17. A client has autoimmune thrombocytopenic purpura. To determine the
client's response to treatment, the nurse would monitor:
Platelet count
White blood cell count
Potassium levels
Partial prothrombin time (PTT): Platelet count
