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?

Body temperature of 99°F or less

Toes moved in active range of motion

Sensation reported when soles of feet are touched

Capillary refill of < 3 seconds

It is important to assess the extremities for blood vessel occlusion in the client with sickle cell anemia because a change in capillary refill would indicate a change in circulation. Body temperature. motion. and sensation would not give information regarding peripheral circulation; therefore. answers A. B. and C are incorrect.

Explanation

It is important to assess the extremities for blood vessel occlusion in the client with sickle cell anemia because a change in capillary refill would indicate a change in circulation. Body temperature. motion. and sensation would not give information regarding peripheral circulation; therefore. answers A. B. and C are incorrect.

2. 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

Taking a trip to the museum is the only answer that does not pose a threat. A family vacation in the Rocky Mountains at high altitudes. cold temperatures. and airplane travel can cause sickling episodes and should be avoided; therefore. answers A. B. and C are incorrect.

Explanation

Taking a trip to the museum is the only answer that does not pose a threat. A family vacation in the Rocky Mountains at high altitudes. cold temperatures. and airplane travel can cause sickling episodes and should be avoided; therefore. answers A. B. and C are incorrect.

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

It is important to keep the client in sickle cell crisis hydrated to prevent further sickling of the blood. Answer A is incorrect because a mechanical cuff places too much pressure on the arm. Answer C is incorrect because raising the knee gatch impedes circulation. Answer D is incorrect because Tylenol is too mild an analgesic for the client in crisis.

Explanation

It is important to keep the client in sickle cell crisis hydrated to prevent further sickling of the blood. Answer A is incorrect because a mechanical cuff places too much pressure on the arm. Answer C is incorrect because raising the knee gatch impedes circulation. Answer D is incorrect because Tylenol is too mild an analgesic for the client in crisis.

4. 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

When there are fewer red blood cells. there is less hemoglobin and less oxygen. Therefore. the client is often short of breath. as indicated in answer B. The client with anemia is often pale in color. has weight loss. and may be hypotensive. Answers A. C. and D are within normal and. therefore. are incorrect.

Explanation

When there are fewer red blood cells. there is less hemoglobin and less oxygen. Therefore. the client is often short of breath. as indicated in answer B. The client with anemia is often pale in color. has weight loss. and may be hypotensive. Answers A. C. and D are within normal and. therefore. are incorrect.

5. 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

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. Bleeding. splenomegaly. and blood pressure changes do not occur. making answers A. B. and C incorrect.

Explanation

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. Bleeding. splenomegaly. and blood pressure changes do not occur. making answers A. B. and C incorrect.

6. 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

Placing the client in semi-Fowler’s position provides the best oxygenation for this client. Flexion of the hips and knees. which includes the knee-chest position. impedes circulation and is not correct positioning for this client. Therefore. answers A. B. and C are incorrect.

Explanation

Placing the client in semi-Fowler’s position provides the best oxygenation for this client. Flexion of the hips and knees. which includes the knee-chest position. impedes circulation and is not correct positioning for this client. Therefore. answers A. B. and C are incorrect.

7. 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) 75 mg IV push

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. Answer A is incorrect because although a warm environment reduces pain and minimizes sickling. it would not be a priority. Answer B is incorrect because although hydration is important. it would not require a bolus. Answer D is incorrect because Demerol is acidifying to the blood and increases sickling.

Explanation

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. Answer A is incorrect because although a warm environment reduces pain and minimizes sickling. it would not be a priority. Answer B is incorrect because although hydration is important. it would not require a bolus. Answer D is incorrect because Demerol is acidifying to the blood and increases sickling.

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

Peaches

Cottage cheese

Popsicle

Lima beans

Hydration is important in the client with sickle cell disease to prevent thrombus formation. Popsicles. gelatin. juice. and pudding have high fluid content. The foods in answers A. B. and D do not aid in hydration and are. therefore. incorrect.

Explanation

Hydration is important in the client with sickle cell disease to prevent thrombus formation. Popsicles. gelatin. juice. and pudding have high fluid content. The foods in answers A. B. and D do not aid in hydration and are. therefore. incorrect.

9. 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 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; therefore. answers A. B. and D are incorrect.

Explanation

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; therefore. answers A. B. and D are incorrect.

10. 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

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. so answer D is incorrect.

Explanation

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. so answer D is incorrect.