PEARSON NCLEX-RN Questions & Rationales.
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 - Correct Answer Semi-Fowler's with legs
extended on the bed
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 - Correct Answer 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.
4. Which of the following foods would the nurse encourage the client in sickle cell crisis to
eat?
Peaches
Cottage cheese
Popsicle
Lima beans - Correct Answer Popsicle.
Hydration is important in the client with sickle cell disease to prevent thrombus formation.
Popsicles, gelatin, juice, and pudding have high fluid content.
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 - Correct Answer 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.
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
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 - Correct Answer 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
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 - Correct Answer 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
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 - Correct Answer 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.
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 indicator?
Conjunctiva of the eye
Soles of the feet
Roof of the mouth
Shins - Correct Answer 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
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 - Correct Answer 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
11. 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?
"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." - Correct Answer "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
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 assessment?
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. - Correct Answer The client had radiation for
treatment 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.
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 - Correct Answer 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.
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?" - Correct Answer "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
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 - Correct Answer Semi-Fowler's with legs
extended on the bed
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 - Correct Answer 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.
4. Which of the following foods would the nurse encourage the client in sickle cell crisis to
eat?
Peaches
Cottage cheese
Popsicle
Lima beans - Correct Answer Popsicle.
Hydration is important in the client with sickle cell disease to prevent thrombus formation.
Popsicles, gelatin, juice, and pudding have high fluid content.
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 - Correct Answer 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.
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
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 - Correct Answer 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
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 - Correct Answer 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
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 - Correct Answer 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.
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 indicator?
Conjunctiva of the eye
Soles of the feet
Roof of the mouth
Shins - Correct Answer 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
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 - Correct Answer 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
11. 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?
"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." - Correct Answer "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
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 assessment?
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. - Correct Answer The client had radiation for
treatment 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.
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 - Correct Answer 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.
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?" - Correct Answer "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
