NCLEX Practice Exam 19 (10 Questions)

1.

A 43-year-old African American male is admitted with sickle cell anemia. The nurse plans to assess circulation in the lower extremities every 2 hours. Which of the following outcome criteria would the nurse use?

Discuss
- A.
  
  Body temperature of 99°F or less
- B.
  
  Toes moved in active range of motion
- C.
  
  Sensation reported when soles of feet are touched
- D.
  
  Capillary refill of < 3 seconds
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?
- A.
  
  Side-lying with knees flexed
- B.
  
  Knee-chest
- C.
  
  High Fowler’s with knees flexed
- D.
  
  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?

Discuss
- A.
  
  Taking hourly blood pressures with mechanical cuff
- B.
  
  Encouraging fluid intake of at least 200mL per hour
- C.
  
  Position in high Fowler’s with knee gatch raised
- D.
  
  Administering Tylenol as ordered
4.

Which of the following foods would the nurse encourage the client in sickle cell crisis to eat?

Discuss
- A.
  
  Peaches
- B.
  
  Cottage cheese
- C.
  
  Popsicle
- D.
  
  Lima beans
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.

Discuss
- A.
  
  Adjust the room temperature
- B.
  
  Give a bolus of IV fluids
- C.
  
  Start O2
- D.
  
  Administer meperidine (Demerol) 75 mg IV push
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?

Discuss
- A.
  
  Roast beef. gelatin salad. green beans. and peach pie
- B.
  
  Chicken salad sandwich. coleslaw. French fries. ice cream
- C.
  
  Egg salad on wheat bread. carrot sticks. lettuce salad. raisin pie
- D.
  
  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 would the nurse recommend?

Discuss
- A.
  
  A family vacation in the Rocky Mountains
- B.
  
  Chaperoning the local boys club on a snow-skiing trip
- C.
  
  Traveling by airplane for business trips
- D.
  
  A bus trip to the Museum of Natural History
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?

Discuss
- A.
  
  Palpate the spleen
- B.
  
  Take the blood pressure
- C.
  
  Examine the feet for petechiae
- D.
  
  Examine the tongue
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?

Discuss
- A.
  
  Conjunctiva of the eye
- B.
  
  Soles of the feet
- C.
  
  Roof of the mouth
- D.
  
  Shins
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?

Discuss
- A.
  
  BP 146/88
- B.
  
  Respirations 28 shallow
- C.
  
  Weight gain of 10 pounds in 6 months
- D.
  
  Pink complexion