NCLEX Select All That Apply Practice Exam 4

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.

Accepted Answer

Tea and coffee are restricted on the day of the test.

Answer

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.

Accepted Answer

"Take pulse rate each day."

Answer

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.

Accepted Answer

Tuck pant legs into socks.

Answer

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.

Accepted Answer

Protect the stoma from water.

Answer

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?

Accepted Answer

The client with a colostomy

Answer

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.

NCLEX Practice Test

NCLEX Practice Test

NCLEX Select All That Apply Practice Exam 4