NCLEX Select All That Apply Practice Exam 4 — Questions and Answers

Question 1: A nurse is providing a list of instructions to a client who is scheduled to have an electroencephalogram (EEG). Choose the instructions that the nurse places on the list. Select all that apply.

Cola is acceptable to drink on the day of the test.
Tea and coffee are restricted on the day of the test. (Correct answer)
The test will take between 45 minutes and 2 hours. (Correct answer)
The hair should be washed the evening before the test. (Correct answer)
All medications need to be withheld on the day of the test.
A nothing-by-mouth (NPO) status is required on the day of the test.

Correct answer: Tea and coffee are restricted on the day of the test.

For an EEG, it's important to avoid stimulants like caffeine (found in tea and coffee) on the day of the test, as they can alter brain wave activity and interfere with results. The hair should be clean and free of products the evening before to ensure good electrode contact. The test duration typically ranges from 45 minutes to 2 hours, depending on the specific protocol and if sleep is induced.

Question 2: The nurse is providing discharge teaching to the client who was given a prescription for nifedipine (Adalat) for blood pressure management. Which instructions should the nurse include? Select all that apply.

"Increase calcium intake."
"Take pulse rate each day." (Correct answer)
"Weigh at the same time each day." (Correct answer)
"Palpitations may occur early in therapy." (Correct answer)
"Be careful when rising from sitting to standing." (Correct answer)

Correct answer: "Take pulse rate each day."

Nifedipine (Adalat) is a calcium channel blocker used for blood pressure management. Clients should be instructed to monitor their pulse rate daily as the medication can affect heart rate. Daily weight monitoring helps detect fluid retention, a potential side effect. Palpitations can occur as a common side effect, especially early in therapy. Orthostatic hypotension is also a risk, so clients should be advised to change positions slowly to prevent dizziness and falls.

Question 3: A nurse is providing teaching regarding the prevention of Lyme disease to a group of teenagers going on a hike in a wooded area. Which of the following points should the nurse include in the session? Select all that apply.

Tuck pant legs into socks. (Correct answer)
Wear closed shoes when hiking. (Correct answer)
Apply insect repellent containing DEET. (Correct answer)
Cover the ground with a blanket when sitting. (Correct answer)
Remove attached ticks by grasping with thumb and forefinger.
Wear long sleeves and long pants in dark colors when in high-risk areas.

Correct answer: Tuck pant legs into socks.

Tucking pant legs into socks creates a physical barrier that prevents ticks from crawling directly onto the skin. This reduces the exposed skin surface area, making it harder for ticks to attach and transmit diseases like Lyme disease. It is a key strategy for tick bite prevention in wooded areas.

Question 4: A nurse is reinforcing instructions to a client following a total laryngectomy about caring for the stoma. Choose the instructions that the nurse provides to the client. Select all that apply.

Protect the stoma from water. (Correct answer)
Soaps should be avoided near the stoma. (Correct answer)
Wash the stoma daily using a washcloth. (Correct answer)
Use diluted alcohol on the stoma to clean it.
Apply a thin layer of petroleum jelly to the skin surrounding the stoma. (Correct answer)
Use soft tissues to clean any secretions that accumulate around the stoma.

Correct answer: Protect the stoma from water.

After a total laryngectomy, the stoma is the client's new airway, leading directly to the lungs. Protecting the stoma from water is crucial to prevent aspiration and potential respiratory infections, as water entering the stoma can go directly into the trachea and lungs. Clients should use a stoma cover when showering or near water.

Question 5: A nurse is reviewing the health records of assigned clients. The nurse plans care knowing that which client is at risk for fluid volume deficit?

The client with cirrhosis
The client with a colostomy (Correct answer)
The client with decreased kidney function
The client with congestive heart failure (CHF)

Correct answer: The client with a colostomy

A client with a colostomy, particularly an ileostomy or ascending colostomy, is at increased risk for fluid volume deficit. This is because the colon's primary function of water and electrolyte absorption is bypassed or significantly reduced, leading to greater fluid loss through the stoma. Close monitoring of output and hydration status is essential.

Question 6: A nurse is told in report that a client has a positive Chvostek's sign. What other data would the nurse expect to find on data collection? Select all that apply.

Coma
Tetany (Correct answer)
Diarrhea (Correct answer)
Possible seizure activity (Correct answer)
Hypoactive bowel sounds
Positive Trousseau's sign (Correct answer)

Correct answer: Tetany

A positive Chvostek's sign is an indicator of hypocalcemia, which increases neuromuscular excitability. This heightened excitability manifests as tetany, characterized by muscle spasms and cramps. Other expected findings with hypocalcemia include a positive Trousseau's sign and potential seizure activity.

Question 7: A nurse lawyer provides an education session to the nursing staff regarding client rights. A nurse asks the lawyer to describe an example that may relate to invasion of client privacy. A nursing action that indicates a violation of this right is:

Threatening to place a client in restraints
Performing a surgical procedure without consent
Taking photographs of the client without consent (Correct answer)
Telling the client that he or she cannot leave the hospital

Correct answer: Taking photographs of the client without consent

Taking photographs of a client without their explicit consent constitutes an invasion of privacy. Clients have a fundamental right to privacy regarding their person and medical information. Using their image without permission violates this right and can lead to legal repercussions for the healthcare provider.

Question 8: A nurse notes in the medical record that a client with Cushing's syndrome is experiencing fluid overload. Which interventions should be included in the plan of care? Select all that apply.

Monitoring daily weight (Correct answer)
Monitoring intake and output (Correct answer)
Maintaining a low-potassium diet
Monitoring extremities for edema (Correct answer)
Maintaining a low-sodium diet (Correct answer)

Correct answer: Monitoring daily weight

Cushing's syndrome often leads to fluid retention due to increased cortisol levels, which have mineralocorticoid effects. Monitoring daily weight is the most sensitive indicator of fluid balance changes, as a rapid weight gain often signifies fluid overload. Other important interventions include monitoring intake/output, assessing for edema, and maintaining a low-sodium diet.

Question 9: A nurse notes in the medical record that a client with Cushing's syndrome is experiencing fluid overload. Which interventions should be included in the plan of care? Select all that apply.

Monitoring daily weight (Correct answer)
Monitoring intake and output (Correct answer)
Maintaining a low-potassium diet
Monitoring extremities for edema (Correct answer)
Maintaining a low-sodium diet (Correct answer)

Correct answer: Monitoring daily weight

Question 10: A client with human immunodeficiency syndrome has gastrointestinal symptoms, including diarrhea. The nurse should teach the client to avoid:

Calcium-rich foods
Canned or frozen vegetables
Processed meat
Raw fruits and vegetables (Correct answer)

Correct answer: Raw fruits and vegetables

Clients with human immunodeficiency syndrome (HIV) and gastrointestinal symptoms like diarrhea are immunocompromised and at higher risk for foodborne illnesses. Raw fruits and vegetables can harbor bacteria, viruses, or parasites that might not be destroyed by cooking, making them unsafe for individuals with weakened immune systems. Cooked and peeled produce is generally safer.

Question 11: A 4-year-old is admitted with acute leukemia. It will be most important to monitor the child for:

Abdominal pain and annorexia
Fatigue and bruising
Bleeding and pallor (Correct answer)
Petechiae and muscosal ulcers

Correct answer: Bleeding and pallor

Acute leukemia in children involves the overproduction of immature white blood cells, which crowds out healthy bone marrow cells. This leads to a decrease in red blood cells (causing pallor and fatigue) and platelets (leading to bleeding tendencies like bruising, petechiae, and epistaxis). Therefore, monitoring for bleeding and pallor is critical.

Question 12: A 5-month-old is diagnosed with atopic dermatitis. Nursing interventions will focus on:

Prevention infection (Correct answer)
Administering antipyretics
Keeping the skin free of moisture
Limiting oral fluid intake

Correct answer: Prevention infection

Atopic dermatitis (eczema) causes dry, itchy skin that is prone to scratching, leading to skin barrier disruption and excoriations. These open areas make the skin highly susceptible to bacterial, viral, or fungal infections. Therefore, a primary nursing intervention is to prevent infection through good skin care, moisturizing, and managing itching.

Question 13: Before administering a nasogastric feeding to a client hospitalized following a CVA, the nurse aspirates 40 mL of residual. The nurse should:

Replace the aspirate and administer the feeding (Correct answer)
Discard the aspirate and withhold the feeding
Discard the aspirate and begin the feeding
Replace the aspirate and withhold the feeding

Correct answer: Replace the aspirate and administer the feeding

When aspirating residual from a nasogastric tube, it is important to return the aspirate to the stomach unless the volume is excessively high. This is because the aspirate contains electrolytes and digestive enzymes essential for maintaining fluid and electrolyte balance and digestion. Replacing it prevents metabolic alkalosis and electrolyte imbalances.

Question 14: A client has an order for Dilantin (phenytoin) .2g orally twice a day. The medication is available in 100mg capsules. For the morning medication, the nurse should administer:

1 capsule
2 capsules (Correct answer)
3 capsules
4 capsules

Correct answer: 2 capsules

The order is for Dilantin 0.2g, and the medication is available in 100mg capsules. To calculate the number of capsules, first convert grams to milligrams: 0.2g = 200mg. Then, divide the total dose by the dose per capsule: 200mg / 100mg/capsule = 2 capsules.

Question 15: The LPN is reviewing the lab results of an elderly client when she notes a specific gravity of 1.006. The nurse recognizes that:

The client has impaired renal function.
The client has a normal specific gravity. (Correct answer)
The client has mild to moderate dehydration.
The client has diluted urine from fluid overload.

Correct answer: The client has a normal specific gravity.

The normal range for urine specific gravity is typically 1.005 to 1.030. A specific gravity of 1.006 falls within this normal range, indicating that the client's urine concentration is appropriate. This value does not suggest impaired renal function, dehydration, or fluid overload.

Question 16: A client with pancreatitis has requested pain medication. Which pain medication is indicated for the client with pancreatitis?

Demerol (meperidine) (Correct answer)
Toradol (ketorolac)
Morphine (morphine sulfate)
Codeine (codeine)

Correct answer: Demerol (meperidine)

Demerol (meperidine) is traditionally preferred for pain management in pancreatitis because it causes less spasm of the sphincter of Oddi compared to morphine. Morphine can cause spasms of the sphincter of Oddi, potentially exacerbating pancreatic pain. Therefore, meperidine is often the indicated choice.

NCLEX Select All That Apply Practice Exam 4

A nurse is providing a list of instructions to a client who is scheduled to have an electroencephalogram (EEG).
Choose the instructions that the nurse places on the list.
Select all that apply.