NCLEX-RN EXAM QUESTIONS WITH VERIFIED
SOLUTIONS NEW MODIFIED CURRENTLY TESTED
AND GRADED A+
The body part that would most likely display jaundice in the dark-skinned
individual is the: --CORRECT ANSWER--Roof of the mouth
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?
--CORRECT ANSWER--Respirations 28 shallow
The nurse is teaching the client with polycythemia vera about prevention of
complications of the disease. Which of the following statements by the client
indicates a need for further teaching? --CORRECT ANSWER--"I will drink
500mL of fluid or less each day."
A 33-year-old male is being evaluated for possible acute leukemia. Which of
the following findings is most likely related to the diagnosis of leukemia? --
CORRECT ANSWER--The client had radiation for treatment of Hodgkin's
disease as a teenager.
Where is the best site for examining for the presence of petechiae in an African
American client? --CORRECT ANSWER--The soles of the feet
Page 1 of 76
,The client is being evaluated for possible acute leukemia. Which inquiry by the
nurse is most important? --CORRECT ANSWER--"Have you had a respiratory
infection in the last six months?"
Which of the following would be the priority nursing diagnosis for the adult
client with acute leukemia? --CORRECT ANSWER--Risk for injury related to
thrombocytopenia
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? --CORRECT
ANSWER--Sexual dysfunction related to radiation therapy
A client has autoimmune thrombocytopenic purpura. To determine the client's
response to treatment, the nurse would monitor: --CORRECT ANSWER--
Platelet count
The home health nurse is visiting a client with autoimmune thrombocytopenic
purpura (ATP). The client's platelet count currently is 80,000. It will be most
important to teach the client and family about: --CORRECT ANSWER--
Bleeding precautions
The client has surgery for removal of a Prolactinoma. Which of the following
interventions would be appropriate for this client? --CORRECT ANSWER--
Elevate the head of the bed 30°.
Page 2 of 76
,The client with a history of diabetes insipidus is admitted with polyuria,
polydipsia, and mental confusion. The priority intervention for this client is: --
CORRECT ANSWER--Check the vital signs.
A client with hemophilia has a nosebleed. Which nursing action is most
appropriate to control the bleeding? --CORRECT ANSWER--Pinch the soft
lower part of the nose.
A client has had a unilateral adrenalectomy to remove a tumor. The most
important measurement in the immediate post-operative period for the nurse to
take is: --CORRECT ANSWER--The blood pressure
A client with Addison's disease has been admitted with a history of nausea and
vomiting for the past three days. The client is receiving IV glucocorticoids
(Solu-Medrol). Which of the following interventions would the nurse
implement? --CORRECT ANSWER--Glucometer readings as ordered
A client had a total thyroidectomy yesterday. The client is complaining of
tingling around the mouth and in the fingers and toes. What would the nurses'
next action be? --CORRECT ANSWER--Check the calcium level.
A 32-year-old mother of three is brought to the clinic. Her pulse is 52, there is a
weight gain of 30 pounds in four months, and the client is wearing two
sweaters. The client is diagnosed with hypothyroidism. Which of the following
Page 3 of 76
, nursing diagnoses is of highest priority? --CORRECT ANSWER--Decreased
cardiac output r/t bradycardia
A 43-year-old African American male is admitted with sickle cell anemia. The
nurse plans to assess circulation in the lower extremities every two hours.
Which of the following outcome criteria would the nurse use? --CORRECT
ANSWER--Capillary refill of < 3 seconds
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? --CORRECT ANSWER--
Semi-Fowler's with legs extended on the bed
A 25-year-old male is admitted in sickle cell crisis. Which of the following
interventions would be of highest priority for this client? --CORRECT
ANSWER--Encouraging fluid intake of at least 200mL per hour
Which of the following foods would the nurse encourage the client in sickle cell
crisis to eat? --CORRECT ANSWER--Popsicle
A newly admitted client has sickle cell crisis. He is complaining of pain in his
feet and hands. The nurse's assessment findings include a pulse oximetry of 92.
Assuming that all the following interventions are ordered, which should be done
first? --CORRECT ANSWER--Start O2
Page 4 of 76
SOLUTIONS NEW MODIFIED CURRENTLY TESTED
AND GRADED A+
The body part that would most likely display jaundice in the dark-skinned
individual is the: --CORRECT ANSWER--Roof of the mouth
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?
--CORRECT ANSWER--Respirations 28 shallow
The nurse is teaching the client with polycythemia vera about prevention of
complications of the disease. Which of the following statements by the client
indicates a need for further teaching? --CORRECT ANSWER--"I will drink
500mL of fluid or less each day."
A 33-year-old male is being evaluated for possible acute leukemia. Which of
the following findings is most likely related to the diagnosis of leukemia? --
CORRECT ANSWER--The client had radiation for treatment of Hodgkin's
disease as a teenager.
Where is the best site for examining for the presence of petechiae in an African
American client? --CORRECT ANSWER--The soles of the feet
Page 1 of 76
,The client is being evaluated for possible acute leukemia. Which inquiry by the
nurse is most important? --CORRECT ANSWER--"Have you had a respiratory
infection in the last six months?"
Which of the following would be the priority nursing diagnosis for the adult
client with acute leukemia? --CORRECT ANSWER--Risk for injury related to
thrombocytopenia
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? --CORRECT
ANSWER--Sexual dysfunction related to radiation therapy
A client has autoimmune thrombocytopenic purpura. To determine the client's
response to treatment, the nurse would monitor: --CORRECT ANSWER--
Platelet count
The home health nurse is visiting a client with autoimmune thrombocytopenic
purpura (ATP). The client's platelet count currently is 80,000. It will be most
important to teach the client and family about: --CORRECT ANSWER--
Bleeding precautions
The client has surgery for removal of a Prolactinoma. Which of the following
interventions would be appropriate for this client? --CORRECT ANSWER--
Elevate the head of the bed 30°.
Page 2 of 76
,The client with a history of diabetes insipidus is admitted with polyuria,
polydipsia, and mental confusion. The priority intervention for this client is: --
CORRECT ANSWER--Check the vital signs.
A client with hemophilia has a nosebleed. Which nursing action is most
appropriate to control the bleeding? --CORRECT ANSWER--Pinch the soft
lower part of the nose.
A client has had a unilateral adrenalectomy to remove a tumor. The most
important measurement in the immediate post-operative period for the nurse to
take is: --CORRECT ANSWER--The blood pressure
A client with Addison's disease has been admitted with a history of nausea and
vomiting for the past three days. The client is receiving IV glucocorticoids
(Solu-Medrol). Which of the following interventions would the nurse
implement? --CORRECT ANSWER--Glucometer readings as ordered
A client had a total thyroidectomy yesterday. The client is complaining of
tingling around the mouth and in the fingers and toes. What would the nurses'
next action be? --CORRECT ANSWER--Check the calcium level.
A 32-year-old mother of three is brought to the clinic. Her pulse is 52, there is a
weight gain of 30 pounds in four months, and the client is wearing two
sweaters. The client is diagnosed with hypothyroidism. Which of the following
Page 3 of 76
, nursing diagnoses is of highest priority? --CORRECT ANSWER--Decreased
cardiac output r/t bradycardia
A 43-year-old African American male is admitted with sickle cell anemia. The
nurse plans to assess circulation in the lower extremities every two hours.
Which of the following outcome criteria would the nurse use? --CORRECT
ANSWER--Capillary refill of < 3 seconds
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? --CORRECT ANSWER--
Semi-Fowler's with legs extended on the bed
A 25-year-old male is admitted in sickle cell crisis. Which of the following
interventions would be of highest priority for this client? --CORRECT
ANSWER--Encouraging fluid intake of at least 200mL per hour
Which of the following foods would the nurse encourage the client in sickle cell
crisis to eat? --CORRECT ANSWER--Popsicle
A newly admitted client has sickle cell crisis. He is complaining of pain in his
feet and hands. The nurse's assessment findings include a pulse oximetry of 92.
Assuming that all the following interventions are ordered, which should be done
first? --CORRECT ANSWER--Start O2
Page 4 of 76
