Grade A+ PEARSON NCLEX-RN Questions & Rationales 2025
Semi-Fowler's with legs extended on the bed
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
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?
Encouraging fluid intake of at least 200mL per hour.
Taking hourly blood pressures with mechanical cuff
It is important to keep the client in sickle cell crisis hydrated to
Encouraging fluid intake of at least 200mL per hour
prevent further sickling of the blood.
Position in high Fowler's with knee gatch raised
Administering Tylenol as ordered
4. Which of the following foods would the nurse encourage the
client in sickle cell crisis to eat? Popsicle.
Peaches Hydration is important in the client with sickle cell disease to
Cottage cheese prevent thrombus formation. Popsicles, gelatin, juice, and pudding
Popsicle have high fluid content.
Lima beans
5. A newly admitted client has sickle cell crisis. The nurse is plan-
ning care based on assessment of the client. The client is com-
plaining of severe pain in his feet and hands. The pulse oximetry
Start O2.
is 92. Which of the following interventions would be implemented
The most prominent clinical manifestation of sickle cell crisis is
first? Assume that there are orders for each intervention.
pain. However, the pulse oximetry indicates that oxygen levels are
Adjust the room temperature
low; thus, oxygenation takes precedence over pain relief.
Give a bolus of IV fluids
Start O2
Administer meperidine (Demerol) 75mg IV push
6. The nurse is instructing a client with iron-deficiency anemia.
Which of the following meal plans would the nurse expect the Egg salad on wheat bread, carrot sticks, lettuce salad, raisin pie
client to select? Egg yolks, wheat bread, carrots, raisins, and green, leafy vegeta-
Roast beef, gelatin salad, green beans, and peach pie bles are all high in iron, which is an important mineral for this client.
Chicken salad sandwich, coleslaw, French fries, ice cream Roast beef, cabbage, and pork chops are also high in iron, but the
Egg salad on wheat bread, carrot sticks, lettuce salad, raisin pie side dishes accompanying these choices are not
Pork chop, creamed potatoes, corn, and coconut cake
7. Clients with sickle cell anemia are taught to avoid activities that
cause hypoxia and hypoxemia. Which of the following activities
A bus trip to the Museum of Natural History
would the nurse recommend?
A family vacation in the Rocky Mountains at high altitudes, cold
A family vacation in the Rocky Mountains
temperatures, and airplane travel can cause sickling episodes and
Chaperoning the local boys club on a snow-skiing trip
should be avoided
Traveling by airplane for business trips
A bus trip to the Museum of Natural History
Examine the tongue
8. The nurse is conducting an admission assessment of a client B12 The tongue is smooth and beefy red in the client with vitamin
deficiency, so examining the tongue should be included in the
with vitamin B12 deficiency. Which of the following would the nurse
physical assessment.
include in 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 outpatient clinic.
Roof of the mouth
The physician suspects vitamin B12 deficiency anemia. Because
The oral mucosa and hard palate (roof of the mouth) are the best
jaundice is often a clinical manifestation of this type of anemia,
indicators of jaundice in dark-skinned persons. The conjunctiva
what body part would be the best indicator?
can have normal deposits of fat, which give a yellowish hue; thus,
Conjunctiva of the eye
, Grade A+ PEARSON NCLEX-RN Questions & Rationales 2025
Soles of the feet answer A is incorrect. The soles of the feet can be yellow if they
Roof of the mouth are calloused, making answer B incorrect; the shins would be an
Shins 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? Respirations 28 shallow
BP 146/88 When there are fewer red blood cells, there is less hemoglobin and
Respirations 28 shallow less oxygen. Therefore, the client is often short of breath
Weight gain of 10 pounds in 6 months
Pink complexion
"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. 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."
12. A 33-year-old male is being evaluated for possible acute The client had radiation for treatment of Hodgkin's disease as a
leukemia. Which of the following would the nurse inquire about as teenager.
a part of the assessment?
Radiation treatment for other types of cancer can result in
The client collects stamps as a hobby.
leukemia. Some hobbies and occupations involving chemicals are
The client recently lost his job as a postal worker.
linked to leukemia, but not the ones in these answers; therefore,
The client had radiation for treatment of Hodgkin's disease as a
answers A and B are incorrect. Answer D is incorrect because the
teenager.
incidence of leukemia is higher in twins than in siblings.
The client's brother had leukemia as a child.
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 petechi- The soles of the feet
ae? Petechiae are not usually visualized on dark skin. The soles of the
The abdomen feet and palms of the hand provide a lighter surface for assessing
The thorax the client for petichiae.
The earlobes
The soles of the feet
14. A client with acute leukemia is admitted to the oncology unit.
"Have you had a respiratory infection in the last 6 months?"
Which of the following would be most important for the nurse to
The client with leukemia is at risk for infection and has often
inquire?
had recurrent respiratory infections during the previous 6 months.
"Have you noticed a change in sleeping habits recently?"
Insomnolence, weight loss, and a decrease in alertness also
"Have you had a respiratory infection in the last 6 months?"
occur in leukemia, but bleeding tendencies and infections are the
"Have you lost weight recently?"
primary clinical manifestations
"Have you noticed changes in your alertness?"
15. Which of the following would be the priority nursing diagnosis
for the adult client with acute leukemia? Risk for injury related to thrombocytopenia
Oral mucous membrane, altered related to chemotherapy The client with acute leukemia has bleeding tendencies due to
Risk for injury related to thrombocytopenia decreased platelet counts, and any injury would exacerbate the
Fatigue related to the disease process problem. The client would require close monitoring for hemor-
Interrupted family processes related to life-threatening illness of a rhage, which is of higher priority
family member
A 21-year-old male with Hodgkin's lymphoma is a senior at the
16.
local university. He is engaged to be married and is to begin a new Sexual dysfunction related to radiation therapy
Radiation therapy often causes sterility in male clients and would
job upon graduation. Which of the following diagnoses would be a
be of primary importance to this client. The psychosocial needs
priority for this client?
of the client are important to address in light of the age and life
Sexual dysfunction related to radiation therapy
, Grade A+ PEARSON NCLEX-RN Questions & Rationales 2025
Anticipatory grieving related to terminal illness
choices. Hodgkin's disease, however, has a good prognosis when
Tissue integrity related to prolonged bed rest
diagnosed early.
Fatigue related to chemotherapy
Platelet count
Clients with autoimmune thrombocytopenic purpura (ATP) have
low platelet counts, making answer A the correct answer. White
17. A client has autoimmune thrombocytopenic purpura. To deter- cell counts, potassium levels, and PTT are not affected in ATP
mine the client's response to treatment, the nurse would monitor:
Platelet count
White blood cell count
Potassium levels
Partial prothrombin time (PTT)
18. The home health nurse is visiting a client with autoimmune
thrombocytopenic purpura (ATP). The client's platelet count cur-
rently is 80, It will be most important to teach the client and family Bleeding precautions
about: The normal platelet count is 120,000-400, Bleeding occurs in
Bleeding precautions clients with low platelets. The priority is to prevent and minimize
Prevention of falls bleeding.
Oxygen therapy
Conservation of energy
19. A client with a pituitary tumor has had a transphenoidal
hyposphectomy. Which of the following interventions would be Elevate the head of the bed 30°
appropriate for this client? Elevating the head of the bed 30° avoids pressure on the sella
Place the client in Trendelenburg position for postural drainage turcica and alleviates headaches. Answers A, B, and D are incor-
Encourage coughing and deep breathing every 2 hours rect because Trendelenburg, Valsalva maneuver, and coughing all
Elevate the head of the bed 30° increase the intracranial pressure.
Encourage the Valsalva maneuver for bowel movements
20. The client with a history of diabetes insipidus is admitted with Check the vital signs
polyuria, polydipsia, and mental confusion. The priority interven- The large amount of fluid loss can cause fluid and electrolyte
tion for this client is: imbalance that should be corrected. The loss of electrolytes would
Measure the urinary output be reflected in the vital signs. Measuring the urinary output is
Check the vital signs important, but the stem already says that the client has polyuria,
Encourage increased fluid intake so answer A is incorrect. Encouraging fluid intake will not correct
Weigh the client the problem, making answer C incorrect.
21. A client with hemophilia has a nosebleed. Which nursing action
Pinch the soft lower part of the nose for a minimum of 5 minutes
is most appropriate to control the bleeding?
The client should be positioned upright and leaning forward, to
Place the client in a sitting position with the head hyperextended
prevent aspiration of blood. Answers A, B, and D are incorrect
Pack the nares tightly with gauze to apply pressure to the source
because direct pressure to the nose stops the bleeding, and ice
of bleeding
packs should be applied directly to the nose as well. If a pack is
Pinch the soft lower part of the nose for a minimum of 5 minutes
necessary, the nares are loosely packed.
Apply ice packs to the forehead and back of the neck
22. Blood pressure
A client has had a unilateral adrenalectomy to remove a tumor.
Blood pressure is the best indicator of cardiovascular collapse in
To prevent complications, the most important measurement in the
the client who has had an adrenal gland removed. The remaining
immediate post-operative period for the nurse to take is:
gland might have been suppressed due to the tumor activity.
Blood pressure
Temperature would be an indicator of infection, decreased output
Temperature
would be a clinical manifestation but would take longer to occur
Output
than blood pressure changes, and specific gravity changes occur
Specific gravity
with other disorders
A client with Addison's disease has been admitted with a history of
nausea and vomiting for the past 3 days. The client is receiving IV Glucometer readings as ordered
glucocorticoids (Solu-Medrol). Which of the following interventions IV glucocorticoids raise the glucose levels and often require cov-
would the nurse implement?
erage with insulin. Answer B is not necessary at this time, sodium
Glucometer readings as ordered
and potassium levels would be monitored when the client is re-
Intake/output measurements
ceiving mineral corticoids, and daily weights is unnecessary
Sodium and potassium levels monitored
Daily weights
Semi-Fowler's with legs extended on the bed
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
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?
Encouraging fluid intake of at least 200mL per hour.
Taking hourly blood pressures with mechanical cuff
It is important to keep the client in sickle cell crisis hydrated to
Encouraging fluid intake of at least 200mL per hour
prevent further sickling of the blood.
Position in high Fowler's with knee gatch raised
Administering Tylenol as ordered
4. Which of the following foods would the nurse encourage the
client in sickle cell crisis to eat? Popsicle.
Peaches Hydration is important in the client with sickle cell disease to
Cottage cheese prevent thrombus formation. Popsicles, gelatin, juice, and pudding
Popsicle have high fluid content.
Lima beans
5. A newly admitted client has sickle cell crisis. The nurse is plan-
ning care based on assessment of the client. The client is com-
plaining of severe pain in his feet and hands. The pulse oximetry
Start O2.
is 92. Which of the following interventions would be implemented
The most prominent clinical manifestation of sickle cell crisis is
first? Assume that there are orders for each intervention.
pain. However, the pulse oximetry indicates that oxygen levels are
Adjust the room temperature
low; thus, oxygenation takes precedence over pain relief.
Give a bolus of IV fluids
Start O2
Administer meperidine (Demerol) 75mg IV push
6. The nurse is instructing a client with iron-deficiency anemia.
Which of the following meal plans would the nurse expect the Egg salad on wheat bread, carrot sticks, lettuce salad, raisin pie
client to select? Egg yolks, wheat bread, carrots, raisins, and green, leafy vegeta-
Roast beef, gelatin salad, green beans, and peach pie bles are all high in iron, which is an important mineral for this client.
Chicken salad sandwich, coleslaw, French fries, ice cream Roast beef, cabbage, and pork chops are also high in iron, but the
Egg salad on wheat bread, carrot sticks, lettuce salad, raisin pie side dishes accompanying these choices are not
Pork chop, creamed potatoes, corn, and coconut cake
7. Clients with sickle cell anemia are taught to avoid activities that
cause hypoxia and hypoxemia. Which of the following activities
A bus trip to the Museum of Natural History
would the nurse recommend?
A family vacation in the Rocky Mountains at high altitudes, cold
A family vacation in the Rocky Mountains
temperatures, and airplane travel can cause sickling episodes and
Chaperoning the local boys club on a snow-skiing trip
should be avoided
Traveling by airplane for business trips
A bus trip to the Museum of Natural History
Examine the tongue
8. The nurse is conducting an admission assessment of a client B12 The tongue is smooth and beefy red in the client with vitamin
deficiency, so examining the tongue should be included in the
with vitamin B12 deficiency. Which of the following would the nurse
physical assessment.
include in 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 outpatient clinic.
Roof of the mouth
The physician suspects vitamin B12 deficiency anemia. Because
The oral mucosa and hard palate (roof of the mouth) are the best
jaundice is often a clinical manifestation of this type of anemia,
indicators of jaundice in dark-skinned persons. The conjunctiva
what body part would be the best indicator?
can have normal deposits of fat, which give a yellowish hue; thus,
Conjunctiva of the eye
, Grade A+ PEARSON NCLEX-RN Questions & Rationales 2025
Soles of the feet answer A is incorrect. The soles of the feet can be yellow if they
Roof of the mouth are calloused, making answer B incorrect; the shins would be an
Shins 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? Respirations 28 shallow
BP 146/88 When there are fewer red blood cells, there is less hemoglobin and
Respirations 28 shallow less oxygen. Therefore, the client is often short of breath
Weight gain of 10 pounds in 6 months
Pink complexion
"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. 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."
12. A 33-year-old male is being evaluated for possible acute The client had radiation for treatment of Hodgkin's disease as a
leukemia. Which of the following would the nurse inquire about as teenager.
a part of the assessment?
Radiation treatment for other types of cancer can result in
The client collects stamps as a hobby.
leukemia. Some hobbies and occupations involving chemicals are
The client recently lost his job as a postal worker.
linked to leukemia, but not the ones in these answers; therefore,
The client had radiation for treatment of Hodgkin's disease as a
answers A and B are incorrect. Answer D is incorrect because the
teenager.
incidence of leukemia is higher in twins than in siblings.
The client's brother had leukemia as a child.
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 petechi- The soles of the feet
ae? Petechiae are not usually visualized on dark skin. The soles of the
The abdomen feet and palms of the hand provide a lighter surface for assessing
The thorax the client for petichiae.
The earlobes
The soles of the feet
14. A client with acute leukemia is admitted to the oncology unit.
"Have you had a respiratory infection in the last 6 months?"
Which of the following would be most important for the nurse to
The client with leukemia is at risk for infection and has often
inquire?
had recurrent respiratory infections during the previous 6 months.
"Have you noticed a change in sleeping habits recently?"
Insomnolence, weight loss, and a decrease in alertness also
"Have you had a respiratory infection in the last 6 months?"
occur in leukemia, but bleeding tendencies and infections are the
"Have you lost weight recently?"
primary clinical manifestations
"Have you noticed changes in your alertness?"
15. Which of the following would be the priority nursing diagnosis
for the adult client with acute leukemia? Risk for injury related to thrombocytopenia
Oral mucous membrane, altered related to chemotherapy The client with acute leukemia has bleeding tendencies due to
Risk for injury related to thrombocytopenia decreased platelet counts, and any injury would exacerbate the
Fatigue related to the disease process problem. The client would require close monitoring for hemor-
Interrupted family processes related to life-threatening illness of a rhage, which is of higher priority
family member
A 21-year-old male with Hodgkin's lymphoma is a senior at the
16.
local university. He is engaged to be married and is to begin a new Sexual dysfunction related to radiation therapy
Radiation therapy often causes sterility in male clients and would
job upon graduation. Which of the following diagnoses would be a
be of primary importance to this client. The psychosocial needs
priority for this client?
of the client are important to address in light of the age and life
Sexual dysfunction related to radiation therapy
, Grade A+ PEARSON NCLEX-RN Questions & Rationales 2025
Anticipatory grieving related to terminal illness
choices. Hodgkin's disease, however, has a good prognosis when
Tissue integrity related to prolonged bed rest
diagnosed early.
Fatigue related to chemotherapy
Platelet count
Clients with autoimmune thrombocytopenic purpura (ATP) have
low platelet counts, making answer A the correct answer. White
17. A client has autoimmune thrombocytopenic purpura. To deter- cell counts, potassium levels, and PTT are not affected in ATP
mine the client's response to treatment, the nurse would monitor:
Platelet count
White blood cell count
Potassium levels
Partial prothrombin time (PTT)
18. The home health nurse is visiting a client with autoimmune
thrombocytopenic purpura (ATP). The client's platelet count cur-
rently is 80, It will be most important to teach the client and family Bleeding precautions
about: The normal platelet count is 120,000-400, Bleeding occurs in
Bleeding precautions clients with low platelets. The priority is to prevent and minimize
Prevention of falls bleeding.
Oxygen therapy
Conservation of energy
19. A client with a pituitary tumor has had a transphenoidal
hyposphectomy. Which of the following interventions would be Elevate the head of the bed 30°
appropriate for this client? Elevating the head of the bed 30° avoids pressure on the sella
Place the client in Trendelenburg position for postural drainage turcica and alleviates headaches. Answers A, B, and D are incor-
Encourage coughing and deep breathing every 2 hours rect because Trendelenburg, Valsalva maneuver, and coughing all
Elevate the head of the bed 30° increase the intracranial pressure.
Encourage the Valsalva maneuver for bowel movements
20. The client with a history of diabetes insipidus is admitted with Check the vital signs
polyuria, polydipsia, and mental confusion. The priority interven- The large amount of fluid loss can cause fluid and electrolyte
tion for this client is: imbalance that should be corrected. The loss of electrolytes would
Measure the urinary output be reflected in the vital signs. Measuring the urinary output is
Check the vital signs important, but the stem already says that the client has polyuria,
Encourage increased fluid intake so answer A is incorrect. Encouraging fluid intake will not correct
Weigh the client the problem, making answer C incorrect.
21. A client with hemophilia has a nosebleed. Which nursing action
Pinch the soft lower part of the nose for a minimum of 5 minutes
is most appropriate to control the bleeding?
The client should be positioned upright and leaning forward, to
Place the client in a sitting position with the head hyperextended
prevent aspiration of blood. Answers A, B, and D are incorrect
Pack the nares tightly with gauze to apply pressure to the source
because direct pressure to the nose stops the bleeding, and ice
of bleeding
packs should be applied directly to the nose as well. If a pack is
Pinch the soft lower part of the nose for a minimum of 5 minutes
necessary, the nares are loosely packed.
Apply ice packs to the forehead and back of the neck
22. Blood pressure
A client has had a unilateral adrenalectomy to remove a tumor.
Blood pressure is the best indicator of cardiovascular collapse in
To prevent complications, the most important measurement in the
the client who has had an adrenal gland removed. The remaining
immediate post-operative period for the nurse to take is:
gland might have been suppressed due to the tumor activity.
Blood pressure
Temperature would be an indicator of infection, decreased output
Temperature
would be a clinical manifestation but would take longer to occur
Output
than blood pressure changes, and specific gravity changes occur
Specific gravity
with other disorders
A client with Addison's disease has been admitted with a history of
nausea and vomiting for the past 3 days. The client is receiving IV Glucometer readings as ordered
glucocorticoids (Solu-Medrol). Which of the following interventions IV glucocorticoids raise the glucose levels and often require cov-
would the nurse implement?
erage with insulin. Answer B is not necessary at this time, sodium
Glucometer readings as ordered
and potassium levels would be monitored when the client is re-
Intake/output measurements
ceiving mineral corticoids, and daily weights is unnecessary
Sodium and potassium levels monitored
Daily weights
