NCLEX Select All That Apply Practice Exam 5

Question 1

The nurse notes that a client is quite suspicious during an assessment interview and believes that her family is under investigation by the CIA.
What would the appropriate nursing interventions be with this client? Select all that apply:

Accepted Answer

Use active listening skills to seek information from the client.

Answer

Tell the client that she is delusional and you can help her.

Answer

Explain to the client that most people are not investigated by the CIA.

Answer

Reassure the client that you are not with the CIA.

Question 2

Which nursing interventions will assist in reducing pressure points that may lead to pressure ulcers? Check all that apply:

Accepted Answer

Avoid use of donut type devices.

Answer

Position the client directly on the trochanter when side lying.

Answer

Massage bony prominences.

Question 3

The nurse is evaluating a client recently diagnosed with primary open angle glaucoma (POAG). What will an important nursing action be? Select all that apply:

Accepted Answer

Review meds the client is currently on to determine whether any of them cause an increased intraocular pressure as a side effect.

Answer

Determine whether the client has any sudden loss of vision accompanied by pain.

Answer

Discuss with the client the importance of controlling blood pressure to decrease the potential loss of peripheral vision.

Answer

Instruct the client to take analgesics as soon as any discomfort occurs in the eye and to notify clinic if pain is not relieved.

Question 4

A nurse understands that a patient may experience pain during peritoneal dialysis because of which of the following? Select all that apply:

Accepted Answer

Too rapid installation

Answer

Warming the dialysate

Answer

Infiltration of the solution into the bloodstream

Answer

Too rapid outflow of the dialysate.

Question 5

The nurse is evaluating a client’s response to hemodialysis. Which lab results will indicate the dialysis was effective? Select all that apply:

Accepted Answer

Serum potassium level decreases from 5.4 to 4.6 mEq/L

Answer

Hgb increases from 10-12 g/dL

Answer

WBC increase from 5000 to 8000/mm^3

Question 6

The nurse understands that the following clinical findings are indications for dialysis. Select all that apply:

Accepted Answer

Volume overload

Answer

BUN 18 mg/dL

Answer

Decreased creatinine clearance.

Question 7

The nurse is assessing a client who had a fractured femur repaired with an external fixator device. Which assessment finding would cause the nurse concern regarding the development of compartment syndrome? Select all that apply:

Accepted Answer

Paresthesia distal to area of injury.

Answer

Decrease in pulse rate in affected leg.

Answer

Complaints that pins are hurting.

Answer

Client angry and calling loudly to the nurse every ten minutes.

Question 8

The nurse is preparing discharge for a patient with GERD. What would be important for the nurse to include in this teaching plan? Select all that apply:

Accepted Answer

Elevate the HOB.

Answer

Increase fluid intake with meals.

Answer

Eat a bedtime snack of milk and protein.

Question 9

The nurse is preparing a client for cardiac catheterization. Which nursing interventions are necessary in preparing the client for this procedure. Select all that apply:

Accepted Answer

Verify consent has been signed.

Answer

Provide clear liquid, no caffeine diet.

Answer

Evaluate peripheral pulses.

Question 10

The physician has prescribed Cytoxan (cyclophosphamide) for a client with nephrotic syndrome. The nurse should:

Accepted Answer

Encourage the client to drink extra fluids

Answer

Request a low-protein diet for the client

Answer

Request a low-protein diet for the client

Answer

Bathe the client using only mild soap and water

Answer

Provide additional warmth for swollen, inflamed joints

The nurse notes that a client is quite suspicious during an assessment interview and believes that her family is under investigation by the CIA.What would the appropriate nursing interventions be with this client? Select all that apply:

The nurse notes that a client is quite suspicious during an assessment interview and believes that her family is under investigation by the CIA.
What would the appropriate nursing interventions be with this client? Select all that apply: