NCLEX-RN Comprehensive Exam Cram with solutions

NCLEX-RN Comprehensive Exam Cram with solutions 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? 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? Semi-Fowler's with legs extended on the bed 00:0701:47 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 Which of the following foods would the nurse encourage the client in sickle cell crisis to eat? 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? Start O2 The nurse is instructing a client with iron-deficiency anemia. Which of the following meal plans would the nurse expect the client to select? Egg salad on wheat bread, carrot sticks, lettuce salad, raisin pie 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 bus trip to the Museum of Natural History The nurse is conducting an admission assessment of a client with vitamin B12 deficiency. Which finding reinforces the diagnosis of B12 deficiency? Beefy tongue The body part that would most likely display jaundice in the dark-skinned individual is the: 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? 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? "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? The client had radiation for treatment of Hodgkin's disease as a teenager. 00:0201:47 Where is the best site for examining for the presence of petechiae in an African American client? The soles of the feet The client is being evaluated for possible acute leukemia. Which inquiry by the nurse is most important? "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? 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? Sexual dysfunction related to radiation therapy A client has autoimmune thrombocytopenic purpura. To determine the client's response to treatment, the nurse would monitor: 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: Bleeding precautions The client has surgery for removal of a Prolactinoma. Which of the following interventions would be appropriate for this client? Elevate the head of the bed 30°.