NCLEX Practice Test 101

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?

1. Body temperature of 99°F or less

2. Toes moved in active range of motion

3. Sensation reported when soles of feet are touched

4. Capillary refill of <>

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?

1. Side-lying with knees flexed

2. Knee-chest

3. High Fowler's with knees flexed

4. 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?

1. Taking hourly blood pressures with mechanical cuff

2. Encouraging fluid intake of at least 200mL per hour

3. Position in high Fowler's with knee gatch raised

4. Administering Tylenol as ordered

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

1. Peaches

2. Cottage cheese

3. Popsicle

4. 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.

1. Adjust the room temperature

2. Give a bolus of IV fluids

3. Start O₂

4. Administer meperidine (Demerol) 75mg 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?

1. Roast beef, gelatin salad, green beans, and peach pie

2. Chicken salad sandwich, coleslaw, French fries, ice cream

3. Egg salad on wheat bread, carrot sticks, lettuce salad, raisin pie

4. 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?

1. A family vacation in the Rocky Mountains

2. Chaperoning the local boys club on a snow-skiing trip

3. Traveling by airplane for business trips

4. 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?

1. Palpate the spleen

2. Take the blood pressure

3. Examine the feet for petechiae

4. 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?

1. Conjunctiva of the eye

2. Soles of the feet

3. Roof of the mouth

4. 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?

1. BP 146/88

2. Respirations 28 shallow

3. Weight gain of 10 pounds in 6 months

4. Pink complexion

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?

1. "I will drink 500mL of fluid or less each day."

2. "I will wear support hose when I am up."

3. "I will use an electric razor for shaving."

4. "I will eat foods low in iron."

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?

1. The client collects stamps as a hobby.

2. The client recently lost his job as a postal worker.

3. The client had radiation for treatment of Hodgkin's disease as a teenager.

4. The client's brother had leukemia as a child.

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?

1. The abdomen

2. The thorax

3. The earlobes

4. The soles of the feet

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?

1. "Have you noticed a change in sleeping habits recently?"

2. "Have you had a respiratory infection in the last 6 months?"

3. "Have you lost weight recently?"

4. "Have you noticed changes in your alertness?"

15. Which of the following would be the priority nursing diagnosis for the adult client with acute leukemia?

1. Oral mucous membrane, altered related to chemotherapy

2. Risk for injury related to thrombocytopenia

3. Fatigue related to the disease process

4. Interrupted family processes related to life-threatening illness of a family member

16. 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?

1. Sexual dysfunction related to radiation therapy

2. Anticipatory grieving related to terminal illness

3. Tissue integrity related to prolonged bed rest

4. Fatigue related to chemotherapy

17. A client has autoimmune thrombocytopenic purpura. To determine the client's response to treatment, the nurse would monitor:

1. Platelet count

2. White blood cell count

3. Potassium levels

4. Partial prothrombin time (PTT)

18. The home health nurse is visiting a client with autoimmune thrombocytopenic purpura (ATP). The client's platelet count currently is 80, It will be most important to teach the client and family about:

1. Bleeding precautions

2. Prevention of falls

3. Oxygen therapy

4. Conservation of energy

19. A client with a pituitary tumor has had a transphenoidal hyposphectomy. Which of the following interventions would be appropriate for this client?

1. Place the client in Trendelenburg position for postural drainage

2. Encourage coughing and deep breathing every 2 hours

3. Elevate the head of the bed 30°

4. Encourage the Valsalva maneuver for bowel movements

20. The client with a history of diabetes insipidus is admitted with polyuria, polydipsia, and mental confusion. The priority intervention for this client is:

1. Measure the urinary output

2. Check the vital signs

3. Encourage increased fluid intake

4. Weigh the client

21. A client with hemophilia has a nosebleed. Which nursing action is most appropriate to control the bleeding?

1. Place the client in a sitting position with the head hyperextended

2. Pack the nares tightly with gauze to apply pressure to the source of bleeding

3. Pinch the soft lower part of the nose for a minimum of 5 minutes

4. Apply ice packs to the forehead and back of the neck

22. A client has had a unilateral adrenalectomy to remove a tumor. To prevent complications, the most important measurement in the immediate post-operative period for the nurse to take is:

1. Blood pressure

2. Temperature

3. Output

4. Specific gravity

23. A client with Addison's disease has been admitted with a history of nausea and vomiting for the past 3 days. The client is receiving IV glucocorticoids (Solu-Medrol). Which of the following interventions would the nurse implement?

1. Glucometer readings as ordered

2. Intake/output measurements

3. Sodium and potassium levels monitored

4. Daily weights

24. A client had a total thyroidectomy yesterday. The client is complaining of tingling around the mouth and in the fingers and toes. What would the nurses' next action be?

1. Obtain a crash cart

2. Check the calcium level

3. Assess the dressing for drainage

4. Assess the blood pressure for hypertension

25. A 32-year-old mother of three is brought to the clinic. Her pulse is 52, there is a weight gain of 30 pounds in 4 months, and the client is wearing two sweaters. The client is diagnosed with hypothyroidism. Which of the following nursing diagnoses is of highest priority?

1. Impaired physical mobility related to decreased endurance

2. Hypothermia r/t decreased metabolic rate

3. Disturbed thought processes r/t interstitial edema

4. Decreased cardiac output r/t bradycardia