PEARSON NCLEX-RN Questions &
Rationales LATEST EXAM VERSION
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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 ans: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 ans: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 ans: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 ans: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 ans: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 ans: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 ans: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 ans: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 ans: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 ans:"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?
Rationales LATEST EXAM VERSION
With Expected real and
comprehensive and Revised Correct
Answers Guarantee Pass A+
Professional Academic Assistance Services
Services Offered
Proctored Exam Assistance
Online Class Management (Full Course Support)
Exam Preparation & Study Materials
Assignments and Coursework Support
Essays and Research Papers
Discussion Posts and Replies
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 ans: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 ans: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 ans: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 ans: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 ans: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 ans: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 ans: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 ans: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 ans: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 ans:"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?
