PEARSON NCLEX-RN Questions & Rationales
1. 2. A 30-year-old male from Haiti is brought to Semi-Fowler's with legs extended
the emergency department in sickle cell crisis. on the bed
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
2. 3. A 25-year-old male is admitted in sickle Encouraging fluid intake of at least
cell crisis. Which of the following interventions 200mL per hour.
would be of highest priority for this client? It is important to keep the client in
Taking hourly blood pressures with mechanical sickle cell crisis hydrated to prevent
cuff further sickling of the blood.
Encouraging fluid intake of at least 200mL per
hour
Position in high Fowler's with knee gatch
raised
Administering Tylenol as ordered
3. 4. Which of the following foods would the nurse Popsicle.
encourage the client in sickle cell crisis to eat? Hydration is important in the client
Peaches with sickle cell disease to pre-
Cottage cheese vent thrombus formation. Popsicles,
Popsicle gelatin, juice, and pudding have
Lima beans high fluid content.
4. 5. A newly admitted client has sickle cell crisis. Start O2.
The nurse is planning care based on assess- The most prominent clinical mani-
ment of the client. The client is complaining of festation of sickle cell crisis is pain.
severe pain in his feet and hands. The pulse However, the pulse oximetry indi-
oximetry is 92. Which of the following interven- cates that oxygen levels are low;
tions would be implemented first? Assume that
, PEARSON NCLEX-RN Questions & Rationales
there are orders for each intervention. thus, oxygenation takes precedence
Adjust the room temperature over pain relief.
Give a bolus of IV fluids
Start O2
Administer meperidine (Demerol) 75mg IV
push
5. 6. The nurse is instructing a client with iron-de- Egg salad on wheat bread, carrot
ficiency anemia. Which of the following meal sticks, lettuce salad, raisin pie
plans would the nurse expect the client to se- Egg yolks, wheat bread, carrots,
lect? raisins, and green, leafy vegetables
Roast beef, gelatin salad, green beans, and are all high in iron, which is an im-
peach pie portant mineral for this client. Roast
Chicken salad sandwich, coleslaw, French fries, beef, cabbage, and pork chops are
ice cream also high in iron, but the side dishes
Egg salad on wheat bread, carrot sticks, lettuce accompanying these choices are not
salad, raisin pie
Pork chop, creamed potatoes, corn, and
coconut cake
6. 7. Clients with sickle cell anemia are taught to A bus trip to the Museum of Natural
avoid activities that cause hypoxia and hypox- History
emia. Which of the following activities would A family vacation in the Rocky Moun-
the nurse recommend? tains at high altitudes, cold tem-
A family vacation in the Rocky Mountains peratures, and airplane travel can
Chaperoning the local boys club on a snow-ski- cause sickling episodes and should
ing trip be avoided
Traveling by airplane for business trips
A bus trip to the Museum of Natural History
7. 8. The nurse is conducting an admission assess- Examine the tongue
ment of a client with vitamin B12 deficiency. The tongue is smooth and beefy red
, PEARSON NCLEX-RN Questions & Rationales
Which of the following would the nurse include in the client with vitamin B12 de-
in the physical assessment? ficiency, so examining the tongue
Palpate the spleen should be included in the physical
Take the blood pressure assessment.
Examine the feet for petechiae
Examine the tongue
8. 9. An African American female comes to the Roof of the mouth
outpatient clinic. The physician suspects vita- The oral mucosa and hard palate
min B12 deficiency anemia. Because jaundice (roof of the mouth) are the best in-
is often a clinical manifestation of this type of dicators of jaundice in dark-skinned
anemia, what body part would be the best indi- persons. The conjunctiva can have
cator? normal deposits of fat, which give a
Conjunctiva of the eye yellowish hue; thus, answer A is in-
Soles of the feet correct. The soles of the feet can be
Roof of the mouth yellow if they are calloused, making
Shins answer B incorrect; the shins would
be an area of darker pigment
9. 10. The nurse is conducting a physical assess- Respirations 28 shallow
ment on a client with anemia. Which of the When there are fewer red blood
following clinical manifestations would be most cells, there is less hemoglobin and
indicative of the anemia? less oxygen. Therefore, the client is
BP 146/88 often short of breath
Respirations 28 shallow
Weight gain of 10 pounds in 6 months
Pink complexion
10.
, PEARSON NCLEX-RN Questions & Rationales
11. The nurse is teaching the client with poly- "I will drink 500mL of fluid or less
cythemia vera about prevention of complica- each day."
tions of the disease. Which of the following The client with polycythemia vera is
statements by the client indicates a need for at risk for thrombus formation. Hy-
further teaching? drating the client with at least 3L of
"I will drink 500mL of fluid or less each day." fluid per day is important in prevent-
"I will wear support hose when I am up." ing clot formation
"I will use an electric razor for shaving."
"I will eat foods low in iron."
11. 12. A 33-year-old male is being evaluated for The client had radiation for treat-
possible acute leukemia. Which of the following ment of Hodgkin's disease as a
would the nurse inquire about as a part of the teenager.
assessment? Radiation treatment for other types
The client collects stamps as a hobby. of cancer can result in leukemia.
The client recently lost his job as a postal work- Some hobbies and occupations in-
er. volving chemicals are linked to
The client had radiation for treatment of leukemia, but not the ones in these
Hodgkin's disease as a teenager. answers; therefore, answers A and B
The client's brother had leukemia as a child. 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 The soles of the feet
acute leukemia. The nurse is assessing for signs Petechiae are not usually visual-
and symptoms of bleeding. Where is the best ized on dark skin. The soles of the
site for examining for the presence of petechi- feet and palms of the hand provide
ae? a lighter surface for assessing the
The abdomen client for petichiae.
1. 2. A 30-year-old male from Haiti is brought to Semi-Fowler's with legs extended
the emergency department in sickle cell crisis. on the bed
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
2. 3. A 25-year-old male is admitted in sickle Encouraging fluid intake of at least
cell crisis. Which of the following interventions 200mL per hour.
would be of highest priority for this client? It is important to keep the client in
Taking hourly blood pressures with mechanical sickle cell crisis hydrated to prevent
cuff further sickling of the blood.
Encouraging fluid intake of at least 200mL per
hour
Position in high Fowler's with knee gatch
raised
Administering Tylenol as ordered
3. 4. Which of the following foods would the nurse Popsicle.
encourage the client in sickle cell crisis to eat? Hydration is important in the client
Peaches with sickle cell disease to pre-
Cottage cheese vent thrombus formation. Popsicles,
Popsicle gelatin, juice, and pudding have
Lima beans high fluid content.
4. 5. A newly admitted client has sickle cell crisis. Start O2.
The nurse is planning care based on assess- The most prominent clinical mani-
ment of the client. The client is complaining of festation of sickle cell crisis is pain.
severe pain in his feet and hands. The pulse However, the pulse oximetry indi-
oximetry is 92. Which of the following interven- cates that oxygen levels are low;
tions would be implemented first? Assume that
, PEARSON NCLEX-RN Questions & Rationales
there are orders for each intervention. thus, oxygenation takes precedence
Adjust the room temperature over pain relief.
Give a bolus of IV fluids
Start O2
Administer meperidine (Demerol) 75mg IV
push
5. 6. The nurse is instructing a client with iron-de- Egg salad on wheat bread, carrot
ficiency anemia. Which of the following meal sticks, lettuce salad, raisin pie
plans would the nurse expect the client to se- Egg yolks, wheat bread, carrots,
lect? raisins, and green, leafy vegetables
Roast beef, gelatin salad, green beans, and are all high in iron, which is an im-
peach pie portant mineral for this client. Roast
Chicken salad sandwich, coleslaw, French fries, beef, cabbage, and pork chops are
ice cream also high in iron, but the side dishes
Egg salad on wheat bread, carrot sticks, lettuce accompanying these choices are not
salad, raisin pie
Pork chop, creamed potatoes, corn, and
coconut cake
6. 7. Clients with sickle cell anemia are taught to A bus trip to the Museum of Natural
avoid activities that cause hypoxia and hypox- History
emia. Which of the following activities would A family vacation in the Rocky Moun-
the nurse recommend? tains at high altitudes, cold tem-
A family vacation in the Rocky Mountains peratures, and airplane travel can
Chaperoning the local boys club on a snow-ski- cause sickling episodes and should
ing trip be avoided
Traveling by airplane for business trips
A bus trip to the Museum of Natural History
7. 8. The nurse is conducting an admission assess- Examine the tongue
ment of a client with vitamin B12 deficiency. The tongue is smooth and beefy red
, PEARSON NCLEX-RN Questions & Rationales
Which of the following would the nurse include in the client with vitamin B12 de-
in the physical assessment? ficiency, so examining the tongue
Palpate the spleen should be included in the physical
Take the blood pressure assessment.
Examine the feet for petechiae
Examine the tongue
8. 9. An African American female comes to the Roof of the mouth
outpatient clinic. The physician suspects vita- The oral mucosa and hard palate
min B12 deficiency anemia. Because jaundice (roof of the mouth) are the best in-
is often a clinical manifestation of this type of dicators of jaundice in dark-skinned
anemia, what body part would be the best indi- persons. The conjunctiva can have
cator? normal deposits of fat, which give a
Conjunctiva of the eye yellowish hue; thus, answer A is in-
Soles of the feet correct. The soles of the feet can be
Roof of the mouth yellow if they are calloused, making
Shins answer B incorrect; the shins would
be an area of darker pigment
9. 10. The nurse is conducting a physical assess- Respirations 28 shallow
ment on a client with anemia. Which of the When there are fewer red blood
following clinical manifestations would be most cells, there is less hemoglobin and
indicative of the anemia? less oxygen. Therefore, the client is
BP 146/88 often short of breath
Respirations 28 shallow
Weight gain of 10 pounds in 6 months
Pink complexion
10.
, PEARSON NCLEX-RN Questions & Rationales
11. The nurse is teaching the client with poly- "I will drink 500mL of fluid or less
cythemia vera about prevention of complica- each day."
tions of the disease. Which of the following The client with polycythemia vera is
statements by the client indicates a need for at risk for thrombus formation. Hy-
further teaching? drating the client with at least 3L of
"I will drink 500mL of fluid or less each day." fluid per day is important in prevent-
"I will wear support hose when I am up." ing clot formation
"I will use an electric razor for shaving."
"I will eat foods low in iron."
11. 12. A 33-year-old male is being evaluated for The client had radiation for treat-
possible acute leukemia. Which of the following ment of Hodgkin's disease as a
would the nurse inquire about as a part of the teenager.
assessment? Radiation treatment for other types
The client collects stamps as a hobby. of cancer can result in leukemia.
The client recently lost his job as a postal work- Some hobbies and occupations in-
er. volving chemicals are linked to
The client had radiation for treatment of leukemia, but not the ones in these
Hodgkin's disease as a teenager. answers; therefore, answers A and B
The client's brother had leukemia as a child. 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 The soles of the feet
acute leukemia. The nurse is assessing for signs Petechiae are not usually visual-
and symptoms of bleeding. Where is the best ized on dark skin. The soles of the
site for examining for the presence of petechi- feet and palms of the hand provide
ae? a lighter surface for assessing the
The abdomen client for petichiae.
