NCLEX Select All That Apply Practice Exam 2 — Questions and Answers
Question 1: A 6-year-old child with leukemia is hospitalized and is receiving combination chemotherapy. Laboratory results indicate that the child is neutropenic, and the nurse prepares to implement protective isolation procedures. Which interventions would the nurse initiate? Select all that apply.
- Restrict all visitors.
- Place the child on a low-bacteria diet. (Correct answer)
- Change dressings using sterile technique. (Correct answer)
- Encourage the consumption of fresh fruits and vegetables.
- Perform meticulous hand washing before caring for the child. (Correct answer)
- Allow fresh-cut flowers in the room as long as they are kept in a vase with fresh water.
Correct answer: Place the child on a low-bacteria diet.
Neutropenia means the child has a severely weakened immune system, making them highly susceptible to infection. A low-bacteria diet (avoiding fresh fruits/vegetables, raw foods) minimizes exposure to microorganisms. Sterile technique for dressings and meticulous hand washing are critical to prevent introducing pathogens, thus implementing protective isolation.
Question 2: A 16-year-old child is brought to the emergency department by his mother with a complaint that the child just experienced a tonic-clonic seizure. On arrival in the emergency department no apparent seizures were occurring. The mother states that her son is taking medication for the seizure disorder. The nurse plans care, knowing that which of the following medications are used for long-term control of tonic-clonic seizures? Select all that apply.
- Diazepam (Valium)
- Alprazolam (Xanax)
- Gabapentin (Neurontin) (Correct answer)
- Ethosuximide (Zarontin) (Correct answer)
- Carbamazepine (Tegretol) (Correct answer)
- Methylphenidate (Ritalin)
Correct answer: Gabapentin (Neurontin)
Gabapentin, Ethosuximide, and Carbamazepine are all anticonvulsant medications commonly used for the long-term management of seizure disorders, including tonic-clonic seizures. Diazepam is typically used for acute seizure management, not long-term control. Alprazolam and Methylphenidate are not primary treatments for tonic-clonic seizures.
Question 3: A child has been diagnosed with meningococcal meningitis. Which of the following isolation techniques is appropriate?
- Enteric precautions
- Neutropenic precautions
- No precautions are required as long as antibiotics have been started.
- Isolation precautions for at least 24 hours after the initiation of antibiotics (Correct answer)
Correct answer: Isolation precautions for at least 24 hours after the initiation of antibiotics
Meningococcal meningitis is transmitted via respiratory droplets, requiring droplet precautions. These precautions are necessary until the client has received at least 24 hours of effective antibiotic therapy. After this period, the risk of transmission significantly decreases, and isolation can often be discontinued.
Question 4: A client enters the emergency department confused, twitching, and having seizures. His family states he recently was placed on corticosteroids for arthritis and was feeling better and exercising daily. On data collection, he has flushed skin, dry mucous membranes, an elevated temperature, and poor skin turgor. His serum sodium level is 172 mEq/L. Choose the interventions that the health care provider would likely prescribe. Select all that apply.
- Monitor intake and output. (Correct answer)
- Monitor vital signs. (Correct answer)
- Maintain sodium-reduced diet. (Correct answer)
- Monitor electrolyte levels. (Correct answer)
- Increase water intake orally. (Correct answer)
- Administer sodium replacements.
Correct answer: Monitor intake and output.
The client's symptoms and serum sodium level of 172 mEq/L indicate severe hypernatremia, likely due to dehydration and possibly corticosteroid use. Interventions focus on correcting fluid balance and reducing sodium. Monitoring I&O, vital signs, and electrolyte levels is crucial for assessing the client's response, while increasing water intake and maintaining a sodium-reduced diet help lower serum sodium.
Question 5: A client has died, and a nurse asks a family member about the funeral arrangements. The family member refuses to discuss the issue. The nurse’s appropriate action is to:
- Show acceptance of feelings.
- Provide information needed for decision making.
- Suggest a referral to a mental health professional.
- Remain with the family member without discussing funeral arrangements. (Correct answer)
Correct answer: Remain with the family member without discussing funeral arrangements.
In this sensitive situation, the family member is clearly not ready to discuss funeral arrangements. The most appropriate nursing action is to provide a supportive presence without pushing the topic. This demonstrates empathy and respect for their grief, allowing them to process their emotions at their own pace.
Question 6: A client is scheduled for a myelogram, and the nurse provides a list of instructions to the client regarding preparation for the procedure. Which instructions should the nurse place on the list? Select all that apply.
- An informed consent will need to be signed. (Correct answer)
- A trained x-ray technician performs the procedure.
- The procedure will take approximately 45 minutes. (Correct answer)
- A liquid diet can be consumed on the day of the procedure.
- Solid food intake needs to be restricted only on the day of the procedure.
Correct answer: An informed consent will need to be signed.
A myelogram is an invasive diagnostic procedure involving the injection of contrast dye into the spinal canal, thus requiring informed consent. The procedure typically takes about 30-60 minutes, so 45 minutes is a reasonable estimate. A myelogram is performed by a radiologist, not an x-ray technician, and specific dietary restrictions are usually required.
Question 7: A client with a closed head injury is receiving phenytoin (Dilantin), an anticonvulsant medication. Which of the following would indicate that the client is experiencing side effects related to this medication? Select all that apply.
- Ataxia
- Sedation
- Constipation (Correct answer)
- Bleeding gums (Correct answer)
- Hyperglycemia (Correct answer)
- Decreased platelet count (Correct answer)
Correct answer: Constipation
Phenytoin (Dilantin) is known to have several side effects, including constipation, bleeding gums (gingival hyperplasia), and hyperglycemia. It can also cause hematological abnormalities like decreased platelet count (thrombocytopenia). These indicate adverse reactions to the medication that require monitoring.
Question 8: A client with carcinoma of the lung develops the syndrome of inappropriate antidiuretic hormone (SIADH) as a complication of the cancer. The nurse anticipates that which of the following may be prescribed? Select all that apply.
- Radiation (Correct answer)
- Chemotherapy (Correct answer)
- Increased fluid intake
- Serum sodium blood levels (Correct answer)
- Decreased oral sodium intake
- Medication that is antagonistic to antidiuretic hormone (ADH) (Correct answer)
Correct answer: Radiation
SIADH is often a paraneoplastic syndrome, meaning it's caused by the cancer itself, so treating the underlying cancer with radiation or chemotherapy is a primary intervention. Monitoring serum sodium levels is crucial as SIADH causes hyponatremia due to excessive water retention. Medications antagonistic to ADH are used to promote water excretion.
Question 9: A client with carcinoma of the lung develops the syndrome of inappropriate antidiuretic hormone (SIADH) as a complication of the cancer. The nurse anticipates that which of the following may be prescribed? Select all that apply.
- Radiation (Correct answer)
- Chemotherapy (Correct answer)
- Increased fluid intake
- Serum sodium blood levels (Correct answer)
- Decreased oral sodium intake
- Medication that is antagonistic to antidiuretic hormone (ADH) (Correct answer)
Correct answer: Radiation
SIADH is often a paraneoplastic syndrome, meaning it's caused by the cancer itself, so treating the underlying cancer with radiation or chemotherapy is a primary intervention. Monitoring serum sodium levels is crucial as SIADH causes hyponatremia due to excessive water retention. Medications antagonistic to ADH are used to promote water excretion.
Question 10: A client with AIDS complains of a weight loss of 20 pounds in the past month. Which diet is suggested for the client with AIDS?
- High calorie, high protein, high fat
- High calorie, high carbohydrate, low protein
- High calorie, low carbohydrate, high fat
- High calorie, high protein, low fat (Correct answer)
Correct answer: High calorie, high protein, low fat
Clients with AIDS often experience significant weight loss and muscle wasting (cachexia) due to the disease process and opportunistic infections. A high-calorie, high-protein diet is crucial to combat this catabolic state, promote weight gain, and support immune function. A low-fat diet is often recommended to prevent malabsorption and reduce gastrointestinal distress, which can be common in AIDS patients.
Question 11: The nurse is caring for a 4-year-old with cerebral palsy. Which nursing intervention will help ready the child for rehabilitative services?
- Patching one of the eyes to strengthen the muscles
- Providing suckers and pinwheels to help strengthen tongue movement (Correct answer)
- Providing musical tapes to provide auditory training
- Encouraging play with a video game to improve muscle coordination
Correct answer: Providing suckers and pinwheels to help strengthen tongue movement
Children with cerebral palsy often have impaired oral motor function, leading to difficulties with speech, swallowing, and feeding. Activities like using suckers and pinwheels encourage lip closure, tongue movement, and breath control, which are essential for developing these skills. Strengthening these muscles through play helps prepare the child for more formal rehabilitative services aimed at improving communication and feeding.
Question 12: At the 6-week check-up, the mother asks when she can expect the baby to sleep all night. The nurse should tell the mother that most infants begin to sleep all night by age:
- 1 month
- 2 month
- 3-4 months (Correct answer)
- 5-6 months
Correct answer: 3-4 months
By 3-4 months of age, most infants begin to establish a more predictable sleep-wake cycle as their central nervous system matures. At this stage, they can typically go longer periods without feeding during the night and consolidate their sleep into longer stretches. While individual variations exist, this age range is a common milestone for infants to start sleeping through the night.
Question 13: Which of the following pediatric clients is at greatest risk for latex allergy?
- The child with a myelomeningocele (Correct answer)
- The child with epispadias
- The child with coxa plana
- The child with rheumatic fever
Correct answer: The child with a myelomeningocele
Children with myelomeningocele (a severe form of spina bifida) are at a significantly higher risk for latex allergy due to repeated exposure to latex products during numerous surgeries, catheterizations, and medical procedures from birth. Their frequent and early exposure to latex sensitizes their immune system, making them more likely to develop an allergic reaction.
Question 14: The nurse is teaching the mother of a child with cystic fibrosis how to do postural drainage. The nurse should tell the mother to:
- Change the child’s position every 20 minutes
- Do percussion after the child eats and at bedtime
- Use cupped hands during percussion (Correct answer)
Correct answer: Use cupped hands during percussion
When performing postural drainage and percussion for cystic fibrosis, using cupped hands creates an air cushion that effectively dislodges thick, sticky mucus from the bronchial walls without causing pain or bruising. Flat hands can be painful and less effective. This technique helps move secretions into larger airways where they can be coughed up, improving lung function and preventing infections.
Question 15: The nurse calculates the amount of an antibiotic for injection to be given to an infant. The amount of medication to be administered is 1.25mL. The nurse should:
- Divide the amount into two injections and administer in each vastus lateralis muscle (Correct answer)
- Give the medication in one injection in the dorsogluteal muscle
- Divide the amount in two injections and give one in the ventrogluteal muscle and one in the vastus lateralis muscle
- Give the medication in one injection in the ventrogluteal muscle
Correct answer: Divide the amount into two injections and administer in each vastus lateralis muscle
For infants, the maximum volume for a single intramuscular injection in the vastus lateralis muscle is typically 1 mL. Since 1.25 mL exceeds this limit, the medication should be divided into two separate injections. The vastus lateralis is the preferred site for IM injections in infants due to its large muscle mass and distance from major nerves and blood vessels.
Question 16: A client with schizophrenia is receiving depot injections of Haldol Decanoate (haloperidol decanoate). The client should be told to return for his next injection in:
- 1 week
- 2 weeks
- 4 weeks (Correct answer)
- 6 weeks
Correct answer: 4 weeks
Haldol Decanoate is a long-acting injectable antipsychotic medication designed for sustained release. It is typically administered every 3 to 4 weeks, with 4 weeks being a common interval to maintain therapeutic drug levels and ensure medication adherence for clients with schizophrenia. This extended dosing schedule helps manage symptoms and prevent relapse.
NCLEX Select All That Apply Practice Exam 2
A 6-year-old child with leukemia is hospitalized and is receiving combination chemotherapy.
Laboratory results indicate that the child is neutropenic, and the nurse prepares to implement protective isolation procedures.
Which interventions would the nurse initiate? Select all that apply.