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
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
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.
We have an expert-written solution to this problem!
4. Which of the following foods would the nurse encourage the client in sickle cell crisis to eat?
Peaches
Cottage cheese
Popsicle
Lima beans
Popsicle.
Hydration is important in the client with sickle cell disease to prevent thrombus formation.
Popsicles, gelatin, juice, and pudding have high fluid content.
We have an expert-written solution to this problem!
,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
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
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
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
We have an expert-written solution to this problem!
,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
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
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
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
We have an expert-written solution to this problem!
, 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."
"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.
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
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?
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
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
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.
We have an expert-written solution to this problem!
4. Which of the following foods would the nurse encourage the client in sickle cell crisis to eat?
Peaches
Cottage cheese
Popsicle
Lima beans
Popsicle.
Hydration is important in the client with sickle cell disease to prevent thrombus formation.
Popsicles, gelatin, juice, and pudding have high fluid content.
We have an expert-written solution to this problem!
,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
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
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
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
We have an expert-written solution to this problem!
,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
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
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
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
We have an expert-written solution to this problem!
, 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."
"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.
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
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?
