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NCLEX EXAM PREVIEW

110 terms kandykat1012Preview NCLEX RN Test 1 2024-2025 Teacher 312 terms TutorDkPreview NCLEX-RN Exam Preview 113 terms lalaitsdestinee Preview NCSBN 408 term AN 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

• 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.

• 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.

• 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.

• 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

• 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

• 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.

• 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

• 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

• 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

• 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.

• 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.

• A client with acute leukemia is admitted to the oncology unit. Which of the following would be most important for the nurse to inquire?

"Have you noticed a change in sleeping habits recently?" "Have you had a respiratory infection in the last 6 months?" "Have you lost weight recently?" "Have you noticed changes in your alertness?" "Have you had a respiratory infection in the last 6 months?" The client with leukemia is at risk for infection and has often had recurrent respiratory infections during the previous 6 months. Insomnolence, weight loss, and a decrease in alertness also occur in leukemia, but bleeding tendencies and infections are the primary clinical manifestations

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

Oral mucous membrane, altered related to chemotherapy Risk for injury related to thrombocytopenia Fatigue related to the disease process Interrupted family processes related to life-threatening illness of a family member Risk for injury related to thrombocytopenia The client with acute leukemia has bleeding tendencies due to decreased platelet counts, and any injury would exacerbate the problem. The client would require close monitoring for hemorrhage, which is of higher priority

• 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 Anticipatory grieving related to terminal illness Tissue integrity related to prolonged bed rest Fatigue related to chemotherapy Sexual dysfunction related to radiation therapy Radiation therapy often causes sterility in male clients and would be of primary importance to this client. The psychosocial needs of the client are important to address in light of the age and life choices. Hodgkin’s disease, however, has a good prognosis when diagnosed early.